HSE apologises for failings in care of Cork father who died by suicide in psychiatric hospital

The HSE has apologised for failings in the care afforded to a Cork father who took his own life in a psychiatric hospital just hours after his admission.

The apology was made after an inquest today into the death almost six years ago of Anthony Hennessy, aged 38, from Gould’s Hill in Mallow, Co Cork, in a room in St Stephen’s Hospital, Glanmire, near Cork city.

The inquest heard the father of two had been a voluntary patient at St Stephen’s for two weeks, just weeks before his death in November 2019, and that he had expressed suicidal thoughts to family members and friends the night before his death.

It heard he had fled from gardaí who were on the lookout for a suicidal man, had crashed his car into a wall at speed, had been arrested under the Mental Health Act, and had been brought by gardaí to St Stephen’s psychiatric hospital amid concerns for his welfare.

However, evidence was heard that on admission, he was not deemed high risk enough for special observations, and his shoelaces were not removed. He was found dead in his room just a few hours later.

The cause of death was recorded as asphyxia due to suspension by a ligature. Coroner Frank O’Connell recorded a narrative verdict.

Mr Hennessy’s wife, Melissa, who was represented by Byron Wade BL — instructed by solicitor John Fintan Daly — fought back tears as the apology was read into the record by Denise Mulcahy BL, on behalf of the HSE and the hospital.

“On behalf of St Stephen’s Hospital, Glanmire, Cork, and its staff, I wish to express my sincere apologies to Anthony’s wife, children, parents, and extended family for the failing in the care afforded to Anthony at this hospital on November 25, 2019,” it read.

“As a hospital, we will endeavour to ensure lessons are learned. We wish to apologise to you unreservedly and offer our heartfelt condolences. We acknowledge the grief and suffering that you and your family continue to endure as a result of Anthony’s death, for which we are truly sorry.”

The inquest heard Mr Hennessy began phoning family members and friends from about 8pm on November 24, 2019, telling them he wanted to take his own life.

His older brother, Kenneth, said Mr Hennessy told their father, Patrick, that he loved him, that he could not have wished for better parents, and asked him to look after his two children — prompting family members to contact gardaí in Mallow with concerns about his mental health.

He said he was with a mutual friend on the northside of Cork city when his brother phoned that friend to say he loved him and “it was time”, and he sounded “cool, calm, and collected” as he said his goodbyes.

Less than a minute later, Mr Hennessy phoned Kenneth to say he had always looked up to him.

Kenneth contacted gardaí in the city and drove to Kilcully Cemetery, where he spotted his brother’s car and followed it into Blackpool, before it sped off towards Farranree where he soon found him at their uncle’s house, and tried to talk him down. However, he said Mr Hennessy was agitated and aggressive, and sped off in the car.

At about 11.30pm, Garda Brian Flynn said gardaí on duty had been alerted about a suicidal man in a white Skoda, and he and his partner spotted the car parked in Knockfree Ave. As they approached, the car drove at their vehicle, forcing them to reverse, before it sped off.

Given the circumstances, Garda Flynn said he deactivated the patrol car’s blue lights and followed the car from a distance down Cathedral Rd, where it crashed at speed into a wall, narrowly missing two pedestrians.

He said when they approached the driver, he lashed out, and they had to use their batons and pepper spray to subdue him, and two sets of handcuffs to restrain him.

They found empty alcohol bottles and a small packet of suspected cocaine in the car, and they arrested Mr Hennessy for intoxicated driving and brought him to Gurranabraher Garda Station, where a doctor who physically examined him did not sign papers to admit him to a psychiatric hospital as an involuntary admission.

Garda Flynn released Mr Hennessy from custody but arrested him immediately under the Mental Health Act, before Kenneth arrived and spoke to his brother, who agreed to a voluntary admission to hospital.

Gardaí took Mr Hennessy first to the Mercy University Hospital for toxicology tests — which were declined — and then to Cork University Hospital, before St Stephen’s agreed to take him at 2.30am.

“I said he was going to the right place and they would look after him,” Kenneth said.

Nikhil Jindal, the registrar on duty at St Stephen’s that night, assessed Mr Hennessy, who said: “I can’t deal with the voices anymore.”

Dr Jindal said based on the fact Mr Hennessy was a voluntary admission, on his previous interactions with him, and on Mr Hennessy’s own assurances he would be safe until his own consultant could assess him later that morning, he made a judgement call that he was not high risk.

Mr Hennessy was seen by nursing staff lying on the bed covers in his room in Unit 4 at about 8.30am on November 25, but was found slumped on the floor inside the door at 9am. Efforts to revive him failed, and he was pronounced dead at the scene.

Clinical nurse manager Ann Murphy, who took up the role at the hospital two years ago, said its current suicide prevention policy directs special nursing observation for patients deemed on assessment to be high risk, the removal of access to potential weapons or ligatures such as belts, that slippers are provided to those with shoes, and regular “ligature risk in room” audits are performed.

The coroner welcomed the measures, but Mr Hennessy’s family said they had come too late for him.

They also expressed regret at the six-year wait for an inquest and that Mr Hennessy’s mother, Marion, did not live to see the outcome.

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