Why was Stephen Loughead's assessment at the Mater Hospital considered a missed opportunity?

Coroner Anne-Louise Toal determined that a significant delay in assessing Stephen Loughead, who was actively suicidal, was a missed opportunity that may have prevented him from leaving the emergency department unnoticed before his death.

What factors contributed to the delay in Stephen Loughead's assessment at the Mater Hospital?

The delay was attributed to "chronic severe pressures" and staffing shortages within the emergency department, which made it impossible to closely monitor the patient or see him by a doctor within the recommended 10 minutes.

What was the outcome for Stephen Loughead after leaving the Mater Hospital unnoticed?

After leaving the hospital unnoticed, Stephen Loughead was later found in the River Lagan and subsequently died from hypoxic brain injury caused by drowning, despite rescue efforts.

Home / Health / Belfast Hospital: Suicidal Patient Left Unnoticed Before Death

Belfast Hospital: Suicidal Patient Left Unnoticed Before Death

10 Feb

•

Summary

Suicidal patient left Belfast hospital unnoticed before death.
Coroner cited delayed assessment as a missed opportunity.
Staffing pressures contributed to the tragic events.

Belfast Hospital: Suicidal Patient Left Unnoticed Before Death

A suicidal patient, Stephen Loughead, 50, left the Mater Hospital's emergency department in Belfast unnoticed shortly before his death in March 2024. Coroner Anne-Louise Toal stated that a delay in assessing Mr. Loughead was a "missed opportunity." He had attended Musgrave PSNI station with deteriorating mental health and was taken to the hospital by police, though officers did not accompany him inside, contrary to guidance.

Mr. Loughead waited over an hour to be triaged, exceeding the 15-minute target. Although triaged as a higher risk category two patient, he could not be closely monitored due to staffing pressures. He was supposed to be seen by a doctor within 10 minutes of being identified as actively suicidal. However, due to "chronic severe pressures" in the ED, he was not called for two hours, by which time he had already left unnoticed.

The coroner found that the environment and protracted wait in the busy unit exacerbated his condition and contributed to his departure. She noted that even today, the situation might not change due to a "chronic lack of resources." Mr. Loughead was later found in the River Lagan and died from drowning, despite rescue efforts.