Ennis mother calls for investigation

AN Ennis mother has called for an independent investigation into the circumstances leading up to the death of her daughter, who died in tragic circumstances after leaving the acute psychiatric unit at Ennis hospital two years ago.
Carol Finn has also called for the introduction of legislation to make it a legal requirement for the Health Service Executive to contact gardaí immediately once an inpatient of a psychiatric unit goes missing.
Sara Finn, 19, went missing from the acute psychiatric unit in Ennis on Friday, June 20, 2008 at 3pm. Her body was found in the grounds of St Flannan’s College, Ennis 24-hours later. Ms Finn claimed Ennis gardaí were not contacted about Sara’s disappearance until 9am on Saturday, while she wasn’t notified until 10am.
Responding to Ms Finn’s call, the HSE has confirmed that Clare Mental Health Services have put protocols in place for dealing with situations where clients leave the psychiatric unit without notifying the clinical team. These involve attempting to contact the client and the family, searching the vicinity and notifying the gardaí.
The health authority has also pointed out that Sara, as an adult, was a voluntary patient at the time she left and was legally free to leave as nursing staff had no authority to detain her.
The jury at an inquest in Ennis Coroner’s Court in June 2009 ruled that her death was in accordance with medical evidence, which recorded that death was due to asphyxia, secondary to a ligature about the neck.
The jury made a recommendation that, “When a patient leaves an acute unit without permission, the gardaí should be informed immediately.”
The inquest heard that Sara Finn had been in the unit on a number of occasions and was on anti-depressants.
However, Carol Finn said she is still not happy with the answers. Calling for an overall review of security at the acute unit, she alleged that Sara had managed to bring blades into the unit and had even managed to hide some of them in the high observation unit.
“There was huge gaps in the service when Sara was a patient in the acute psychiatric unit. I believe there should be a comprehensive review of security in the unit.
“There was no security employed to check people coming in to see if they had alcohol or drugs. The only security was a keypad. Sara managed to bring in razors to cut herself and ended up in the A&E department on three occasions.
“I had to go to three doctors in April 2008 to get her admitted as an involuntary patient. The HSE told me they never found her paperwork yet she was in the hospital for eight weeks. They wanted to send her home but I kept fighting for her to stay and I refused to take her home because I felt she needed help from a team of doctors. I thought I was doing the right thing,” she said.
A solicitor representing the HSE apologised to Sara’s family at the coroner’s court.
“Sara’s death has destroyed my life. I would like to get a few straight answers and get some changes to ensure the same thing doesn’t happen to another teenager,” she said.
In a statement issued to The Clare Champion, the HSE acknowledged the death of an adult son or daughter is a grievous blow for any parent and the authority was aware that the expressions of sympathy it made in the past to Mrs Finn were of limited usefulness in assuaging her grief over the tragic death of Sara.
In some respects, the authority explained, it was constrained by the need to avoid saying anything that might in any way add to Mrs Finn’s continuing distress.
“It is not our policy to discuss security measures at hospitals or psychiatric units in any detail as experience in the past has found that two dangers can arise from this. It reduces their effectiveness and can present a challenge to disturbed persons to overcome security,” a HSE spokesman explained.
The Mental Health Commission (MHC) urged management at the acute psychiatric unit in Ennis to implement a policy on searches to tackle the problems the unit faced with illicit drugs and alcohol earlier this year.
One of the breaches uncovered by the Inspectorate of Mental Health Services at the 39-bed unit on June 3, 2009 last was the absence of a proper search policy. Following inspection, the service submitted a policy to the Inspectorate on searches, which was implemented in July 2009 and is due for revision in July 2011.