AN estimated £200,000 has been spent improving security arrangements at the Tyrone and Fermanagh Hospital in Omagh following a series of reports that highlighted the need for changes after the tragic death of Fivemiletown man Ernest Kells.
On the final day of the inquest into Mr Kells’ death, senior Western Trust official Claire Maguire, Service Lead Nurse for Older People’s Mental Health Services and Head of Service for the past year at Oak Villa, outlined the measures taken in response to the lessons learned from the 2021 tragedy.
Mr Kells had been an inpatient at Oak Villa in the days leading up to April 2, 2021, when he left the unit through an unlocked door. His body was later recovered from the nearby Camowen River.
Coroner Maria Dougan is expected to deliver her findings at a later date following the conclusion of the inquest into his death this week.
During the final day of evidence on Thursday, it was revealed that it took 14 weeks for the doors at Oak Villa to be repaired, and that a Freedom of Information request confirmed six patients, including Mr Kells, had previously left the facility through the same door in the ten years up to 2021.
Following his death, a Serious Adverse Incident Report was completed, and the RQIA carried out an inspection in August and September 2022. Asked whether she could assure the Kells family that issues had now been addressed, Ms Maguire replied, “Absolutely.”
“We now have a triple-door system. The front door has a keypad, which leads to an inner door accessible only to staff with a swipe card. There is then swipe access into the ward itself, and we have done away with the doorbell,” she said.
“Staff now go and meet any visitors to the ward and bring them through. The alarm, which was an interim measure, is no longer in place.”
Before these new arrangements, staff had carried out half-hourly door audits, and a temporary ‘screamer alarm’ had been installed.
Additional signage was also erected to remind staff to ensure the door was locked.
“An inner door was erected around April 2021 with a swipe pass. A business case to replace the front door was made in 2023/2024,” Ms Maguire added.
CCTV cameras
New CCTV cameras were also installed last year to cover all entry and exit points on the hospital site. It is hoped that, in the event of a similar incident, the footage would help staff quickly identify where someone may have left the premises.
Ms Maguire confirmed that the proximity of the Camowen River and associated risks had been discussed.
“The river was discussed and the risks associated with it. But we have no control over the land and surrounding areas. It was discussed putting barriers up around the river,” she said.
However, those additional measures were ultimately not implemented.
At earlier hearings, the inquest heard that the ward door was not locked on the night Mr Kells disappeared. His son described him as a ‘kind and caring man’ whose mental health had deteriorated during the Covid lockdown, leading to his voluntary admission to Oak Villa for treatment for severe depression and psychosis.
Evidence was given that he was seen only once by a doctor during his first week on the ward. Concerns were also raised about his care, including a lack of detailed management notes and a distressing incident during which he was showered by a female staff member.
On the night of his disappearance, CCTV captured Mr Kells leaving the ward unnoticed, but there were no external cameras to trace his movements. It later emerged that a psychiatrist overseeing his care had declined requests for a face-to-face review due to time pressures, while staff reported that he had previously attempted to open the same door on several occasions.
Police were contacted shortly after he left the ward, and officers joined staff in searching the hospital grounds, but Mr Kells’ body was recovered from the Camowen River the following day.