A breakdown in communication between hospital staff has been highlighted as a contributing factor in the death of Derry man Harry Jack whose body was found in a field three days after he went missing from Altnagelvin Hospital on Hallowe'en night in 2006.
An inquest into the 45 year-old's death yesterday heard how a message from a member of the public, who had seen Mr Jack walk into a cemetery on Church Brae shortly after he left the hospital in an agitated state, had not been passed on to the relavent staff member in the hospital or to the PSNI who were investigating his disappearance.
A chronic alcoholic, Mr Jack had been admitted to hospital on October 30 after suffering a seizure. During the course of his treatment for alcohol withdrawal he became agitated and hallucinated on a number of occasions before being detained under the Mental Health Order for fear that he would be a danger to himself or others.
Mr Jack had already absconded from the hospital on two occasions earlier that day - on one occasion being found in the adjacent Northern Bank in his bare feet - but had been persuaded to return to the hospital for further treatment.
The Coroner's Court heard how, on the third occasion, Mr Jack had pushed past the on call social worker and an auxiliary nurse before ignoring pleas from medical staff and hospital porters to stay.
A request for back-up from a psychiatric nurse from Gransha to be seconded to Altnagelvin overnight to help care for Mr Jack had been turned down due to a lack of resources. Hospital staff had also requested that a police officer be made available on the ward, but this too was turned down as police resources in Derry were stretched on the night of his disappearance due to the Hallowe'en festivities.
The court heard how hospital staff witnessed Mr Jack leave the hospital grounds while Sister Majella Doran, who was in charge of the AMU at the time, reported his disappearance to police.
She also passed on a message from a member of the public who reported seeing Mr Jack on Daly's Brae however a message from another member of the public, Mrs Yvonne Porter, who said she had spoken to Mr Jack and had seen him enter the cemetery at Church Brae was not passed onto police.
Therese Brown, Head of Clinical Quality and Safety at the Trust said that the nurse who had taken this message "did not appreciate the value of passing on this information and had believed the police already had it".
Mr Jack's body was discovered three days later in a field at Rushill Road. His death was attributed to hypothermia and chronic alcoholism. Coronor Ms. Suzanne Anderson said there had been a 'breakdown of communication' in the hospital and she would be writing to the Trust to advise them of her findings and to try and ensure such a tragedy did not occur again.