A mentally ill patient was found dead in the grounds of the Ulster Hospital at Dundonald 10 weeks after he vanished from one of the wards, a Police Ombudsman's report has revealed.
An incompetent police investigation failed to locate James Fenton, 22, from Bangor, Co Down, and it was only after his desperate family insisted on a fresh search that he was eventually recovered in secluded woods - just 40 metres from where he went missing - the report found.
Mr Fenton's mother said the memory of the police errors would last forever. Janice Fenton said: "I live with the pain of never having been able to see James again, never getting to say goodbye. The worst thing for all of us is knowing he was so near the hospital ward. James lay out in the open, cold and alone for all that time. That's my heartache and the memory I will have forever."
A post-mortem examination was unable to establish how he died. But a damning report by the Police Ombudsman Dr Michael Maguire, who headed a probe into the PSNI investigation, disclosed an extraordinary catalogue of mistakes.
The family had been completely let down by the police, he said. Twelve officers have been disciplined.
Dr Maguire declared: "We found many examples of where police procedures were either not fully followed or completely ignored. There was little evidence of any consistent senior oversight of the investigation and it was largely allowed to drift along until its latter stages."
Almost three hours after he was admitted as a voluntary patient he was given access to a designated smoking area. But Mr Fenton, who was recorded as at "high risk" of committing suicide, climbed over a fence outside the mental health ward just before midnight on July 2, 2010.
The Ombudsman's report said it was recognised that police officers will on occasions make wrong operational decisions. But it also declared: "The investigation into James' disappearance is a catalogue for mistake after mistake with no effective method to review and thus identify and rectify the errors made."
Mrs Fenton said: "We had no liaison officer, not much help with media coverage, we even put up missing posters ourselves. I believe that, only for my family's persistence, the search which led to him being found, 10 weeks later, would not have happened."
PSNI Chief Superintendent Nigel Grimshaw said it was a human tragedy and after expressing his sympathy to the family said he was sorry they did not have confidence in the policing service they received. He added: "There is no doubt we have learned lessons from this investigation. We have already taken significant steps to improve the management of missing persons investigations and we will continue to study the conclusions reached by the Police Ombudsman."