“It became clear during evidence, that members of staff are not aware of what is required…”

The coroner’s concerns

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— (1) It became clear during evidence, that members of staff are not aware of what is required of them when they carry out Observations on a patient. This was particularly evident with regard to Observations to be carried out on a “two members of staff to one patient’ basis. Areas of confusion include how staff are to engage with a patient, how close they are required to be with regard to the patient, i.e. at arm’s length or within eyesight and how to record the information gained from the Observation. _ (2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police. In particular, Mr Higgins who had been acting in an unpredictable and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him. The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins; . . (3) The safety of the environment where the incident took place, namely a disabled ramp with a railing along the edge and a concrete’floor, had not been risk assessed prior to taking Mr Higgins outside for a cigarette. It is understood that since Mr Higgins’ death the railing has been heightened. There was no evidence of a formal Risk Assessment having been undertaken since his death. Other ways of making the area safe are still under consideration. (4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who. require assessment and treatment at A & E, as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area, having already self-harmed and shown signs of paranoia.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2015-0480

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0