Dedicated self harm nurses have been appointed at a Dublin hospital following the death of a man who jumped from the fifth floor.
The 40 year old man died after he broke the window in his single occupancy room at the Mater Hospital early in 2015.
The man, who'd been admitted four days previously with self inflicted wounds, was waiting for a bed in his local psychiatric hospital.
He sustained a punctured lung and was placed in an acute medical ward on the fifth floor.
As his medical condition improved, staff discussed his transfer to St Vincent's Psychiatric Hospital in Fairview but there were no beds available.
Staff discussed his transfer to the Mater Hospital's psychiatric ward on the ground floor but he was not transferred because it was not hospital protocol, Dublin Coroner's Court heard.
Protocol at the hospital has since changed, according to solicitor for the Mater Hospital, Kevin Power.
The man's family was not informed of his admission to hospital at his request, the court heard.
A psychiatric registrar who conducted an evaluation said the man told her he did not trust himself and felt safe in hospital. He had been hospitalised for multiple previous suicide attempts and had chronic thoughts of this nature, the court heard.
"He was apologetic for what he had done. He said 'I'm sorry for thinking this way, I know it's ridiculous,'" the psychiatric registrar said.
Shortly after midnight on the man's fourth day in hospital he broke the window in his room and climbed onto the ledge. A female patient in another ward saw him and ran to alert staff.
"I realised this poor man might be about to jump. I prayed they could get to him on time," she said.
The man jumped before staff could reach him and died of multiple injuries. The hospital conducted a review following the incident and introduced a process designed to manage psychiatric patients admitted with acute medical issues.
Such patients are now treated and ideally transferred to their local psychiatric hospital. If no bed is available they will be treated at the psychiatric ward at Mater Hospital, St Aloysius Ward, on the ground floor.
If no bed is available there, the patient will be treated in a medical isolation unit located on the ground floor. If no bed is available there, the patient will be treated on an acute medical ward with supervision. The level of supervision depends on a psychiatric evaluation.
The jury returned a verdict of death by suicide and recommended the protocols introduced at the Mater be adopted at hospitals nationwide.
© Irish Examiner Ltd. All rights reserved