Coroner blasts 'inadequate' police response over vulnerable Jonathan
A coroner has slammed a police investigation into a missing man - who was later hit by a train - as "inadequate" and "deeply unsatisfactory".
Coroner Joe McCrisken made the criticisms on the final day of an inquest into the death of 29-year-old Jonathan Magee, who died after walking out of A&E at Belfast City Hospital in the early hours of January 29, 2011.
Mr Magee, who had mental health problems, had been waiting for seven hours to be sectioned when he walked out of the building.
A top police officer apologised twice to the Magee family during the inquest for the PSNI's flawed investigation, which resulted in eight officers being disciplined.
In an unusual move, Coroner McCrisken placed a framed picture of Jonathan with his mother on the his bench throughout yesterday's proceedings.
He said Mr Magee was a man with clear mental health problems who health officials had decided to admit as an inpatient just two days before he went into the Belfast hospital. "He arrived at the hospital at around 6pm, but by 1.10am the process to admit him had still not been completed and he decided to leave. I consider this process was unsatisfactory and did not meet his needs," he said.
"It seems to me that the out-of-hours GP provision was also insufficient and led to an unnecessary delay in admission. Again, I think the fact that the hospital staff were faced with a man who was compliant and patient led them to consider he was not a risk of flight, but a look at his previous history might have led to a different conclusion and I am satisfied that Julie (Jonathan's sister) made staff aware that he had left the Mater Hospital some days before."
Following his disappearance, staff at the hospital contacted police to report him missing. However, Mr McCrisken said the police reaction to this report was "inadequate" and failed the family of Mr Magee.
"Those failings were frankly and correctly acknowledged by the officer who took the initial call. As a result of this officer's failure to follow the relevant service procedure and request further details, opportunities were lost during that first and crucial golden hour following Jonny's disappearance.
"It's difficult for me to conclude that these failings directly led to his death, but it is reasonable to assume that if a police officer had attended the hospital when requested then at least they would have a better chance of finding Jonny… and bringing him back for the psychiatric treatment that he clearly required. A fair summary of the entire missing person's investigation in this case is that it lacked coherence, it lacked good communication and lacked direction. Inspector (John) McIntyre frankly considered the investigation of missing persons in 2011 as a shambles."
He added that none of the officers involved actively considered a PSNI service procedure which was specifically put in place to deal with missing person investigations.
He said that when actions were taken which did comply with that procedure it seemed to be that this was "more of an accident than design".
He added: "This is a crucial failing and one which I found to be deeply unsatisfactory.
"Superintendent Sean Wright, who is a very senior police officer, said that the family did not receive the service they ought to have expected from the PSNI.
"The PSNI has apologised for the failings of this missing persons investigation.
"I'm satisfied beyond reasonable doubt that Mr Magee took his own life and that it was his intention to do so when he stepped in front of the train."