Trust apology for man’s ‘untimely death’ at Derry mental health unit

Davin Corrigan, from Sion Mills, died at Grangewood Hospital, Gransha, in November 2018.

The Trust said it wanted to offer its sincere apologies to the Corrigan family for Davin’s “untimely death” while in its care.

The Trust said it accepted in full the findings and recommendations of a report carried out by a Serious Adverse Incident review team following Mr Corrigan’s death.

This report concluded that Davin’s death “in that way and at that time” was preventable.

The report found that the Trust’s systems for recording and scrutinising incidents of self-harm in its mental health facilities were not robust.

It also found there was a delay in modifying the hospital environment to reduce risk which contributed to Davin’s untimely death.

The review also concluded there were failings to properly scrutinise adverse incident reports to identify themes and patterns of risk and to take decisive action to manage or mitigate the risk when it was identified.

The Trust says it has implemented a number of recommendations following the Serious Adverse Incident report and these include:

* Trust incident identification and reporting procedures have been changed and improved as a result.

• Modifications to the hospital environment.

• Improved governance arrangements.

• Improved data capturing and analysis.

• Significant progress in respect of incident management.

• Frequency of supervision.

• Review of safety plans.

In a letter to the Corrigan family, the Trust’s chief executive, Ann Kilgallon, and its chairman, Sam Pollock, note that Davin had been “in our care for some time and many staff in the hospital and the community were deeply attached to him”.

The letter adds: “We are sorry that Davin did not have an updated safety plan at that time and that an opportunity to involve his family in developing a safety plan was missed. We are sorry that opportunities were missed to effectively involve you, his family, in his assessment and treatment planning and we are sorry that the Trust’s response to you immediately following your bereavement and for some time thereafter was wholly inadequate.

“As identified in the SAI report, our systems for recording and scrutinising incidents of self-harm in our mental health facilities were not robust and resulted in nine similar incidents being coded inappropriately. The report also highlighted that there was a delay in modifying the hospital environment to reduce risk which contributed to Davin’s untimely death. For all of this we are truly sorry. We wish to assure you that we have taken action in regard to these matters and that this process has been overseen by the RQIA. Our incident identification and reporting procedures have been changed and improved as a result.”

Their letter ends: “We wish to say again to you, as parents, how sorry we are for the loss of your dear son, Davin, and to acknowledge the pain and hurt you have experienced.”

The family of Davin Corrigan, meanwhile, have welcomed the “fulsome apology” from the Trust.

A statement, on behalf of his parents, Dessie and Aisling, his siblings Leon, Justin, Brandon, and Sophie, said that it particularly welcomed the Trust’s recognition that Davin’s death was preventable “if timely actions had been taken whilst he was under the care of Grangewood Hospital”.

The statement adds: “The fact that the Serious Adverse Incident report acknowledges that opportunities were missed in 2014, 2015, 2016, 2017 and 2018, in itself highlights how let down Davin was during his time in Grangewood.”

The family say the Serious Adverse Incident review has set out clearly that there were failings at every level.

The statement adds: “Davin was clearly and without doubt failed at every single level of care, ironically by the very care system that was meant to be looking after him.”

The family statement concludes: “Davin was a very special son, grandson, brother, and uncle. He loved life and wherever he was everyone enjoyed his company – Davin truly lit up the room. He loved MMA boxing. We know how proud he would be today that we are continuing to fight his corner to get to the truth, in his memory. Today, finally, we have got the answers to the questions and more importantly the truth that Davin deserves.”