Taoiseach Micheál Martin has described a review into mental health services in south Kerry as shocking, very serious and unacceptable.
Mr Martin said there will be a full nationwide audit of compliance with Child and Adolescent Mental Health Services (Camhs) operational guidelines by all teams.
He said a prescribing audit will also be conducted in each of the 72 Camhs teams nationally and the Government will look at “any further measures required”.
The Health Service Executive (HSE) report published on Wednesday morning said hundreds of children received "risky" treatment from a doctor working in mental health in south Kerry and significant harm was caused to 46 of them.
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More than 11,700 children and teenagers accessed mental health services last year
The review was into allegations that young people who attended mental health services in south Kerry were prescribed inappropriate medication.
The review examined the treatment of more than 1,300 young people who attended the South Kerry Camhs over a four-year period.
The risks involved in the treatment by the doctor included sleepiness, dulled feelings, slowed thinking and serious weight gain and distress, according to the review.
Mr Martin was responding in the Dáil to Social Democrats co-leader Róisín Shortall during Leaders’ Questions on Wednesday, who asked if there would be a wider inquiry into Camhs services around the country.
Mr Martin said the findings demand “a fundamental review” of services, and not just those in south Kerry, and that it was not a “resources issue”.
He said the first principle of medicine is to do no harm, but children had been harmed by “a complete failure of clinical performance and oversight and the entire management of the service”.
“There was a systemic collapse here in terms of overall clinical governance and in terms of the overall management of the service,” he said.
“I think any review view has to look end to end because questions were raised in the very fundamental decision itself, of saying you will have NCHD [non-consultant hospital doctor] in charge of a community area. People may have made a call at the time but even that has to be interrogated in terms of best practice.”
Mr Martin said there was a broader issue around recruitment of qualified personnel generally, “which we know we need to face up to”.
Ms Shortall said the review was “shocking and distressing” for all of the families involved and that some children would have been waiting up to two years to access the service.
“Instead of helping their children the service actually harmed them,” she said.
The Dublin North-West TD said the treatment of the whistleblower involved, a locum consultant psychiatrist who has since resigned from the HSE, raises very serious questions about the treatment of whistleblowers in State agencies.
HSE report
The HSE report said: “This incident is the result a large number of events relating to the care and treatment of children, attending the Team A clinic, by a non-consultant hospital doctor, culminating in unreliable diagnoses, inappropriate prescriptions and poor monitoring of treatment and potential adverse effects. These events exposed many children unnecessarily to the risk of significant harm.”
Having reviewed 1,332 files, the authors of the report found no extreme or catastrophic harm was caused to the patients in these files. Not all of the children who the doctor worked with were put at risk of harm, they found.
The care and treatment of 13 other children by other doctors was also risky, the review found, and the authors found proof of significant harm to 46 children.
This harm included production of breast milk, putting on a lot of weight, being sleepy during the day and raised blood pressure.
The junior doctor whose work came under scrutiny did not co-operate with the review. According to the report, another staff member heard the person “was running a private treatment service from their home, sometimes seeing people privately up to midnight, and was also working in a private clinic in another county”.
Enumerating the key causal factors behind events, the review said the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) for secondary school children was often made “without the right amount of information from their teachers on how the children were at school”.
Checks of observations of unwanted effects of medications “did not happen”, including pulse, blood pressure, and height and weight.
“These observations were not regularly checked or not recorded properly. Necessary blood tests were not always done. The doctor was not available for interview.
“We believe that the doctor thought they were helping the patients and did not intend to harm the patients they treated.
“The exposure of the children to risk and harm by the doctor was because of lack of knowledge about the best way to do things.”
The review also identified key contributory factors including the fact there was no clinical lead for the Camhs Area A Team. “This was one of the reasons for failing to provide and keep a high-quality service.”
In addition, there was no consultant child and adolescent psychiatrist from 2016 for the Camhs Area A Team.
While another consultant child and adolescent psychiatrist agreed to cover the vacant post until it was filled, it was expected that it would only be for a short while.
“It took much longer than expected to find someone to fill the vacant position. Not enough attention was paid to the possible risks while this job was vacant.”
The consultant psychiatrist supervising the doctor did not see problems that developed throughout 2017 and 2018.
Concerns
Concerns about the doctor were first reported in 2018, but no proof was found that these concerns were addressed after being reported.
In 2019 concerns about prescribing medication were clear, according to the report, and the supervisor at the time advised changes but did not insist these happened.
The doctor worked extra hours and was observed to be very tired at work, but this issue was not addressed.
There was no system used to check the prescribing of medications or the quality of service by the doctor’s supervisors, the review stated.
In 2020, the doctor was recommended for other jobs even though there were concerns about him. And while a new senior medical manager started in the service, the concerns about the doctor were not handed over to this person.
According to the review, the service has not put in place many of the recommendations of the National Camhs Operating Procedure 2015 or the Camhs Operational Guideline 2019.
It did not have updated treatment plans that were shared with the patient, their family and the person who referred them to Camhs, nor did it name a key worker in all cases, a team co-ordinator or a practice manager.
The Camhs Area A team had a lot more referrals of new patients than other areas across the country, and this had not reduced at the same rate as other services.
Some of the referrals that were not accepted were not dealt with quickly and were left awaiting on a decision of acceptance.
There was no shared diary, and reception staff did not know who was coming in for appointments. “Staff cannot quickly know who is working on a case. All of this means cases get lost.”
Rules on looking after case files were not being followed properly. Staff and doctors were able to take files from the file room without signing them out, against HSE policies on the management of health records.
In addition, clinical information was not always recorded in the patient file.
The review said there is proof of two referrals and 10 full case records being missing; these have been reported in line with data protection rules.
While the Camhs has a governance group, this did not check it was working safely and effectively, or talk about the risks of a long-term vacancy.
Recommendations
The review made 35 recommendations, including:
- Children and their families should be invited to be part of the governance structure of the Camhs service.
- The recruitment of a permanent, full-time clinical lead consultant psychiatrist must remain a priority for the service.
- Community healthcare organisation (CHO) managers in the HSE should think about setting up a working group to look at the current and future needs of Camhs.
- Training for all staff in risk and incident management. "Across Ireland, the head of the CHOs and the senior doctors should be told about the risks for their teams which have not had consultants for a long time."
Response
Responding to the review, the HSE repeated earlier apologies it had made to the 46 young people and their families who suffered serious harm, and to all 240 young people “who did not receive the care they should have”.
“Young people and their families are entitled to expect a high standard of care when they attend our services, and the report makes it clear that this did not happen in a large number of cases,” Michael Fitzgerald, chief officer of Cork Kerry Community Healthcare, which has responsibility for HSE mental health services in Kerry, said.
“As chief officer of the organisation, I apologise sincerely to the young people and their families for this. I want to reassure the young people and their families that we have taken on board the 35 recommendations in the report, and will implement them as quickly as we can.”
The review team was led by an external Camhs consultant, Dr Seán Maskey, from the Maudsley Hospital in London, who travelled to Ireland to carry out this work.
The HSE has already apologised to about 250 families for substandard care identified in the review.
The review was prompted by concerns expressed by a whistleblower in the health service who alleged substandard treatment of clients of South Kerry Camhs.
The HSE initially looked at the files of about 50 young people who attended the service, after which it was decided to carry out a “look-back” review of all files between July 2016 and April 2021.
The report was posted to affected families on Tuesday, and a copy has been sent to Minister for Health Stephen Donnelly.
The HSE is operating an information line for those affected – 1800 742 800 – which is open from 8am to 8pm, seven days a week.
