Coroner says PSNI must learn lessons over the suicide of vulnerable man freed from custody
A coroner is writing to the Chief Constable urging that lessons are learned over a Belfast father who took his own life hours after being released from police custody.
James McCotter, known as Jim, was 29 when he was found dead by his family in his flat at Woodbourne Court on the night of August 12, 2012.
His family had called police that morning after they found him drunk and threatening to kill himself at his flat.
He was arrested for being intoxicated, a breach of a previous bail condition, and after a struggle with officers was taken to Musgrave PSNI station.
Despite repeated warnings to police from the family about his high suicide risk, he was released that evening.
At the conclusion of his inquest yesterday, Coroner Suzanne Anderson found Mr McCotter had taken his own life, but said the PSNI needed to reflect on its care of suicidal detainees.
The concerns centred on an examination of Mr McCotter by a police doctor and the decision to release him, against advice, by a custody sergeant.
In delivering her findings, Ms Anderson noted Mr McCotter - whose occupation was listed as an unemployed industrial painter - had a history of drug and alcohol abuse and had previously attempted suicide.
When he was taken to Musgrave, his family's concerns and the fact he had told police he would be "dead by morning" were recorded in a custody record.
Mr McCotter was constantly monitored in his cell by CCTV and physically checked every 15 minutes.
That afternoon he was inspected in his cell for about 30 seconds by the forensic medical officer, Professor John Farnan, who had not been briefed about the suicide risk.
Professor Farnan's paperwork advised Mr McCotter was fit to be detained with a sobriety check in two to three hours and indicated a further medical review was needed at the custody sergeant's discretion.
In court, Professor Farnan said he meant only the time of the medical examination was discretionary, but Ms Anderson ruled this was "ambiguous".
After 6pm a duty inspector advised that Mr McCotter should be kept in overnight due to his suicide risk.
This was relayed to the custody sergeant, Diane Armstrong, whose shift had just started.
But despite the advice, she took the decision to release him at 7pm without informing the family.
Aine McCotter only found out her brother had been released when she called to check up on him two hours later.
By 10pm her stepfather Stephen Lagan found a suicide note on Mr McCotter's front door, before discovering his body in the kitchen.
A Police Ombudsman investigation into the death at the time made several recommendations to the PSNI, most of which were accepted.
Ms Anderson commented: "Given that so many detained persons threaten to take their own lives or self-harm whilst in custody - around 90% - I will be sending a copy of my findings to the Ombudsman and the Chief Constable.
"That is in the hope that lessons will be learned from Mr McCotter's tragic death."
Aine said: "It's not going to bring Jim back but hopefully it's never going to happen to anyone else again.
"The station doctor tried his best.
"But what he meant on paper was confusing."
She added: "He loved his family so much and he believed that he was stressing us out the last year of his life so much where he felt our lives would be easier without him.
"Obviously he was wrong, he was just amazing.
"He used to go to the shop for my mummy's elderly neighbours and he just doted on his wee son Ryan (now aged 10), who lives in Scotland and misses his daddy loads."