The man collapsed last Tuesday.
Staff at the Mendicity Institution, a homeless day centre, called an ambulance, said Louisa Santoro, the CEO. It came fast.
He spent three days in intensive care before he passed away, says Santoro. “He never regained consciousness as far as we know.”
He was 31, from Lithuania, and had been a regular at the Mendicity Institution, spending days there and sleeping rough on Dublin’s streets at night, she says.
Why did he die? The answer depends on how deep you want to go.
Santoro tells a story of his life in the past year that draws in precarious work, and bureaucratic rules around access to homeless hostels, and around access to most detox facilities.
Each death of a homeless person warrants a full review into all the circumstances that lead up to it, says Santoro.
Not to apportion blame, but to learn from any mistakes and make changes to services if necessary, she says. “This death potentially could have been prevented if we had better access to services.”
Two separate pieces of research are set to look more deeply at the issue of increased deaths among those who are homeless.
The DRHE and HSE are reviewing homeless deaths in Dublin in 2020. The Health Research Board plans to go through coroner’s files nationally and compile data on homeless people who died in 2019.
But one key question is how well the research promised by these state agencies will go beyond the more immediate causes of death, and grapple with the role of barriers to supports, and the complicated histories of those who have died.
Behind the Figures
In 2020, 79 homeless people died in the Dublin region.
That was an increase from 49 in 2019, 47 in 2018 and 62 in 2017, according to a Dublin Region Homeless Executive report issued to the Dáil housing committee.
There are more single homeless people now than there were at the start of 2019, says the report. “The number of single persons in hostel-type accommodation has increased by over 800 in the past two years.”
Of those who died in 2020, 44 were living in emergency hostels run by private operators or charities, while 27 were in long-term supported accommodation, such as supported flats or hostels. Eight people died on the streets.
This time last year, the Lithuanian man had been working a cash-in-hand job as a mushroom picker, says Santoro. But he lost that job before the pandemic and wasn’t able to prove he had been working.
He also couldn’t prove he had been “habitually resident in Ireland”, so he wasn’t entitled to social welfare, says Santoro.
“He had no income from March last year to the time he died and it doesn’t make anyone’s circumstances better,” she says. “You need to be made of iron to pull yourself out of that kind of disadvantage.”
He had been drinking more and going downhill fast and her staff were worried, says Santoro.
But they couldn’t get him a place in an alcohol detox facility because, again, he wasn’t eligible for most, she said.
(The Dublin Simon Community detox accepts people who don’t have a social-welfare payment but their service was full, she says.)
Without what’s known as a “local connection”, the man couldn’t get a bed in a supported hostel either, she says.
He had stayed in several privately run hostels with no support. He was beaten up twice, often missed his curfew, and ended up sleeping rough, she says.
He slept outside all winter, she says.
The DRHE and the HSE are conducting a review into the deaths in the Dublin region in 2020, said Dublin City Council Housing Manager Brendan Kenny, at the Oireachtas Housing Committee on 29 January.
“Obviously we are concerned about the increase in numbers and we have a very comprehensive review being carried out by the HSE and Dr Austin O’Carroll and we will be publishing that,” he said.
He says he is doing a “desktop review” of the deaths of homeless people that occurred in 2020.
That will look at age, gender, where the person died, and how they died – if that information is available. He is currently trying to get as many coroner’s reports as possible, he said.
That research will show whether there was an increase in suicides and overdoses or if most of the deaths were due to long-term illnesses, he says.
It is important to track whether an increased number of people are dying while sleeping rough, he says.
Dr O’Carroll says that 79 is not a huge jump from 62 in 2017 so “it could be normal variation”, he says. “It is very sad. That is why we are trying to look into it.”
The Health Research Board is to carry out a separate one-year study, collating data about the deaths of homeless people nationwide in 2019, using coroners’ reports.
“The research will use a similar approach to that used for the National Drug Related Deaths Index,” says a spokesperson for the Health Research Board.
The index is a census of drug-related deaths and deaths among people who use drugs or are alcohol-dependent. That research involves looking at hospital files and treatment records also.
The research into homeless deaths is only looking at the coroners’ reports and will not include reviewing support plans.
Some charities already have their own review processes, and have been changing how they do things based on what they learn.
Last year saw a spike in deaths among clients of the homeless charity Novas, said Dr Una Burns, head of policy and communications, at a meeting of the Oireachtas Housing Committee on Friday.
Thirteen people died in Novas services in 2020, she said. (In 2018, six people died, and in 2019, seven people died.)
They have had more clients. But the increase was disproportionate, she said.
Novas staff noticed a significant increase in self-harm, suicideal ideation, and suicide attempts among clients in 2020, so they gave staff special training and equipment, said Burns.
The charity has trained staff in “trauma-informed care”, which helps them to better support clients, said Burns.
They trained staff, too, to administer Naloxone, a drug that can save the life of an opiate user who has overdosed. “We need Naloxone to be rolled out to all homeless services,” said Burns.
People who have completed addictions-rehabilitation programmes need drug-free hostels too, she said.
Trying to Understand
Mike Allen, director of advocacy with Focus Ireland, says it does an internal review whenever someone dies in its services.
Some deaths are expected and are attributable to long-term illnesses, he says. But sudden deaths, including suicides and accidents, often warrant investigation.
“We would err on the side of having a further investigation if it is a grey area,” he said, by phone.
Focus Ireland staff go to the site and talk to all witnesses, Allen says. They look at the person’s history, what happened on the day, and any medical reports or other relevant documents, he says. “There is a framework.”
The final report might detail whether procedures were followed and recommend changes. The CEO of Focus Ireland reviews these reports, Allen says.
It’s important to identify misjudgments or procedural errors, says a Focus Ireland report to the Oireachtas housing committee. But “it is important to avoid the perception that investigations of death are a process for ‘apportioning blame’.”
At that committee’s meeting on Friday, Sinn Féin housing spokesperson Eoin Ó Broin TD said that the HSE or DRHE should carry out a review each time a homeless person dies – similar to the adult-safeguarding reviews done by UK agencies.
Reviews are not about blame, but to allow service providers to “look back when people die in services or in care, to see how the care can be improved in the future for other users”, said Ó Broin.
Dr O’Carroll says he is trying to develop a process called a “safety management plan” so that all sudden deaths would be fully reviewed, including talking to all the services involved with the person.
“We are looking at developing a process going forward where we review that so we can learn from it,” he says. “We do need to have a learning mechanism.”
Says Santoro: “It is about trying to understand, if there were failings, how can we prevent this from happening in the future?”
Earlier this week, Santoro was busy trying to arrange for her client’s body to be cremated so his ashes could be flown back to his family in Lithuania.
The state will pay for a cremation if the person had been on social welfare, says Santoro. But her client wasn’t, so there’s no obvious funding stream to cover this step in getting his remains back home.