Admission incomplete notes led to gap in care

Ian Loughran was found dead in his home on July 19, 2021. PHOTO: ODT FILES

A medical professional has admitted incomplete paperwork created a gap in a Dunedin poet’s care before his death.

Ian Loughran was found dead in his home on July 19, 2021, aged 55, and this week in the Dunedin District Court, Coroner Mary-Anne Borrowdale is overseeing an inquest into his death.

Mr Loughran was a poet, well-known volunteer and award-winning stand-up comedian.

He read his poems for audiences around the globe and wrote numerous plays, as well as hosting two radio shows.

The inquest will explore six points, including the competency of Mr Loughran’s care and communication between specialists.

On Monday, the court heard from a member of Mr Loughran’s family, who talked about his downward spiral.

The woman, who has name suppression, said she was "greatly concerned" about aspects of his mental healthcare in the months before his death and made wide-reaching assertions.

Mr Loughran had missed a scheduled appointment with psychiatrist Dr Chris Wisely on the day of his death.

The next day, Dr Wisely called the family member.

She thought the call was "inappropriate" and the psychiatrist was "fishing for information".

Yesterday, a tearful Dr Wisely said he was "mortified" to learn he had offended the woman and was certainly not fishing for information.

"I wholeheartedly apologise that this is the way I came across to [the family member]," he said.

"The purpose of my call was to offer my condolences and understand where things had gone wrong for Mr Loughran."

He said when Mr Loughran did not show up to his appointment, he was not alarmed.

"In most cases there is a simple reason for people not attending appointments and this happens a lot," he said.

"If I’d known that [the family] was worried about him on that day I would have organised for myself or someone from my team to go to his home."

Yesterday, another health professional, who has name suppression, gave evidence a lack of communication meant incomplete paperwork was never brought to his attention.

He said that meant Mr Loughran did not receive his injectable medication as he was meant to.

Counsel assisting the coroner Sally Carter asked the witness about his contact with Mr Loughran.

"Do you accept in hindsight ... that there seems to have been a gap that he fell through?" she asked.

"The answer to that is yes," the witness replied.

"Had I been informed of that incomplete paperwork I would have ensured that the [hospital] staff completed it so he could be followed up ... "

The witness said matters were complicated because Mr Loughran refused post-discharge care from the North Community Mental Health team and intended to see a private psychologist and his GP instead.

Ms Carter also asked the witness about whether it was appropriate to discharge Mr Loughran from hospital after the statutory five-day period.

He said it was, and that Mr Loughran could no longer be in the secure ward because he did not meet the criteria under the Mental Health Act.

"The entire team who saw Mr Loughran over that period noted that both his psychosis and his mania had settled very rapidly," the witness said.

"He evinced a desire to return home and to continue with [his injectable medication] ... he agreed to see me again on the 18th of February 2021 for a post-discharge follow-up."

But Mr Loughran did not show up and attempts to contact him failed.

"It was decided that the appointment would not be rescheduled and Mr Loughran was discharged to the care of his GP," the medical professional explained.

The family member with name suppression questioned that decision and asked "who took the reins" in terms of seeing through his discharge treatment plan.

She pointed out the medical professional told Mr Loughran’s GP the appointment would be re-booked and did not update him when that changed and he was discharged.

"How were you confident that somebody else would step up and be able to check on Ian?" she asked.

The witness said he relied on Mr Loughran keeping his appointment with his psychologist and GP or contacting Emergency Psychiatric Services.

"Mr Loughran made a choice, that choice was that he was uncontactable both on the 18th and 19th. I’m not going to assume that means he was mentally unwell at the time," the witness said.

He said in retrospect, he should have told the GP Mr Loughran was discharged with no follow-up appointment rescheduled.

The inquest is expected to continue for the week.