Seán Boyle, from Dromintee, died on June 1, 2020, aged 24.
In Seán Boyle:Death on the Ward, reporter Alan Haslam speaks to his mother Sinéad Boyle.
She said he was a “great fella” with a lot of promise and a bright future ahead of him, and was interested in a career in farming.
However, he also battled serious mental health challenges.
In 2020, within hours of being admitted to the Bluestone Unit, he was “able to take his own life”.
“Seán killed himself with his own belt, a belt that had been taken from him on safety grounds but later returned with fatal consequences,” the reporter said.
“I thought he was in a place of safety and not only was he not in a place of safety, they gave him the means to end his life,” his mother said.
The Southern Health Trust is currently under police investigation for corporate manslaughter, the programme said.
Sinéad told Spotlight her son’s mental health problems were exacerbated when he started taking drugs in his teens and also turned to self-harming.
As the years passed, his struggle with drink and drugs continued, he had suicide attempts and was hearing messages.
On May 27, 2020, Seán was admitted to the Bluestone Unit, after his mother contacted mental health services in Newry, believing he needed specialist help.
He was assessed by two doctors, who decided he should be temporarily detained and that he was at risk of harming himself.
An investigation report, commissioned by the Southern Trust following Seán’s death, said that during the night a member of the nursing staff took away his belt, locking it in a bedside cabinet, even though more senior staff previously allowed him to keep it.
Later, when he asked for it, the same member of staff gave it back to him.
On May 28, Seán was found unresponsive by the clinical team and died three days later in intensive care, with Covid preventing his family from being with him in person.
“I had all these questions and .. always wonder from how he went from ‘no, I don’t want to die’ to later being dead. What happened? I’m still not clear,” his mother said.
Figures from the RQIA show that 14 mental health inpatients have died since 2017.
The programme said a letter from the Department of Health to the Southern Trust following the death raised concerns about another patient who had attempted suicide in a similar way at Bluestone seven months earlier.
The report also uncovered another issue, which led police to begin investigating the apparent falsification of records around Seán’s care.
The report said it “could not be confident Seán was observed as prescribed within every 15-minute period as written on the observation sheet”.
During police interview, the staff member conceded they had made a mistake.
According to police notes seen by the programme they were recorded as being left deeply impacted by the incident.
In a statement, the Southern Trust said Seán’s death was the subject of a coroner’s investigation, in which it is fully engaged, along with a police investigation.
It told the BBC it was unable to comment on specific issues as a result.
The trust offered its condolences to the family and said it will continue to offer them support.
It said it had implemented a range of measures at Bluestone to improve the quality and safety of care.
Spotlight said it had seen police notes which suggest it is unlikely the trust will be prosecuted.
Sinead Boyle said that since her son’s death she “had fought for the truth” and that she wants to remember her son for the “amazing, kind, hardworking person that he was”.
“The sad part about this is that it didn’t need to be like this,” she added.
The programme will be shown on BBC1 at 10.40pm and on iPlayer.