CUH patient who died by suicide did not have access to medication for two days, inquest hears

Prescribed antidepressant was unavailable due to 'sourcing issues' at hospital pharmacy

The inquest heard Oliver McCarthy, a patient in the psychiatric ward at CUH, expressed frustration about his medication just 10 minutes before his death on December 14, 2022. Picture: Larry Cummins

A Cork University Hospital patient who died by suicide did not have access to a prescribed antidepressant for the two days leading up to his death due to “sourcing issues”, an inquest has heard.

The inquest heard Oliver McCarthy, a 47-year-old father of two from Kinsale in Cork, expressed frustration about his medication just 10 minutes before his death on December 14, 2022.

Mr McCarthy, who was voluntarily admitted to the psychiatric ward at CUH at the end of October, was also to be given overnight leave that day.

CUH consultant psychiatrist Dr Tom Cronin said he had met with Mr McCarthy for a care treatment plan meeting shortly before his death.

“He was frustrated at the poor response of the new medication and he was also frustrated that the CUH pharmacy hadn’t sourced it in the last two days,” he said.

A close friend for more than 20 years, Con O’Connell said Mr McCarthy was “disconcerted” the medication he was prescribed was not available.

“This is the sad thing about our health service, of all the places you would hope that the medication would be available,” he said.

Mr O’Connell said his friend “felt vulnerable in that scenario”, being somewhere that was supposed to be a safe place but instead was “malfunctioning”.

Mr McCarthy was discovered in his room by housekeeping staff who then raised the alarm. Resuscitation attempts lasted for 40 minutes before he was pronounced dead.

Dr Cronin expressed his “sincere condolences” to Mr McCarthy’s family.

The inquest heard Mr McCarthy was prescribed several different medications, including two used to treat anxiety. However, Dr Cronin said tranylcypromine was the sole antidepressant prescribed.

He said tranylcypromine had not been dispensed from the CUH pharmacy “due to sourcing issues and he had not received it for the last two days”.

“I personally sourced tranylcypromine from a local pharmacy on the day of his death,” he said adding recommencing the medication was discussed that day with Mr McCarthy.

He was taking the antidepressant for about two weeks when he died, with the inquest hearing a course of antidepressants can take at least two weeks before any signs of improvement.

His sister Maura Feehan said her brother had spoken about suicide at the prospect of being discharged, which she raised with staff two days before his death, who told her he was not showing any signs of intent.

“I think what you all saw and what we, his family, saw was completely different,” she said before also raising concerns her brother “had the equipment to do it” while an inpatient.

Dr Cronin said access to certain objects in rooms was prohibited depending on the patient, however, hospital staff were unaware of certain items in Mr McCarthy’s possession which were used in his death.

He explained belongings were checked when a patient was admitted but were not thereafter unless there was a specific reason. He added he would have removed certain items had he known.

Dr Cronin said the ward was “relatively large”, with the location of patients being documented, while regular reviews of mental state are carried out every few days.

He said patients are regularly reviewed and assessed for suicidality and Mr McCarthy had not been deemed at risk of suicide during his admission.

He said environmental risks have been examined, with plans to make structural changes within the ward as a result.

Cork City Coroner Philip Comyn told Mr McCarthy’s family and friends he would be writing to HSE chief executive Bernard Gloster and Health Minister Stephen Donnelly recommending that information arising from events such as this should be shared among hospitals.

State Pathologist Dr Margot Bolster gave the cause of death as asphyxiation.

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