Dunedin poet Ian Loughran died after lack of follow-up care

Clinicians failed to give a Dunedin poet follow-up care and medication after he left a mental health ward, denying him his best chance of recovery before he died by suicide, a coroner has found.

Ian Loughran, who suffered from bipolar disorder, died in July 2021 following two hospital admissions earlier that year.

In findings released on Wednesday following an inquest, coroner Mary-Anne Borrowdale said Loughran’s mental health care fell below standards in ways that contributed to his death.

“While it is not possible to say that Mr Loughran’s death would have been prevented had these errors not occurred, the periods in which he was largely unmedicated and lost to care deprived him of the best chance of recovery from his mental illness,” she said.

The coroner said Loughran worked as a compliance officer and was a busy and well-loved member of Dunedin’s literary scene.

The 55-year-old was a performance poet, playwright and comedy writer who recorded music and radio shows.

Loughran was first sectioned and taken to a secure ward at Wakari Hospital for five days in February 2021 after his wife became worried about his paranoid behaviour.

He was admitted again a month later after his mental state “rapidly deteriorated” and his wife reported angry, intense and paranoid behaviour and reckless spending.

Coroner Borrowdale said Loughran was treated with an injection of depot olanzapine and responded well during his first stay but was discharged without a plan for his next injection of a mood-stabilising medication that was indispensable to his wellbeing because of missing paperwork.

An official discharge summary prepared at the time also failed to provide clear advice to Loughran or his GP about his medication, warning signs of a relapse or how to access help in a crisis, the coroner said.

“I find that there was a lack of comprehensive and integrated follow-up that led to Mr Loughran not attending community mental health services and not receiving his essential medication, without which his rapid deterioration was virtually assured,” she said.

After his second stay in hospital, Loughran went 11 weeks without any specialist follow-up.

The coroner said he was supposed to have a dedicated worker looking after him but no-one was appointed.

“Clinical records misleadingly describe Mr Loughran as then going ‘AWOL’ and ‘avoid[ing] being seen by our services’ after his discharge,” she said.

“It would be more accurate to state that EPS [the emergency psychiatric service] avoided having any contact with Mr Loughran. Between 15 April and 18 June, the NCMHT [north community mental health team] made no attempt to contact Mr Loughran, despite him having just been discharged from a lengthy (23 day) complex inpatient admission, his second within a few short months.”

Loughran was found dead on 19 July 2021.

The last clinician to visit him was a consultant psychiatrist on 25 June, while a psychiatric nurse had also tried to contact him in early July to arrange a follow-up visit.

In the three weeks before his death, Loughran went without vital monitoring of his mood, the coroner said.

“We do not know what signs of depression or suicidality Mr Loughran might have shown if he had been seen. But that is the very nature of this failing: Mr Loughran should have been supported in making his way back to wellness. Rather, he was left on his own to manage on his own.”

Health New Zealand carried out a critical incident review of Loughran’s death and decided to introduce verbal handovers between inpatient and outpatient consultants at the point of inpatient discharge.

The agency had since deemed that measure “not achievable”, coroner Borrowdale said.

“This response provides no reassurance at all that what happened to Mr Loughran could not reoccur,” she said.

“It is disappointing to see that Health NZ has not implemented its own recommendation for verbal handovers…to my mind, a one-to-one handover of this kind between responsible clinicians is vital and should be treated as an indispensable requirement.”

The coroner made 12 recommendations to Health NZ.

She said discharge summaries should be timely and comprehensive, include advice tailored to the patient and make clear which senior clinician was accountable for their care.

She also recommended formal protocols for medication clinics, including written acceptance of referrals and direct communication with the responsible psychiatrist if there were delays or other issues.

Coroner Borrowdale said Loughran’s hospital treatment was satisfactory and was unlikely to have contributed to his death, although he and his family were badly let down by the disconnectedness of his discharge.

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