Inspectors at a psychiatric unit in Cavan General Hospital investigated a “serious” incident where a patient was administered electro-convulsive therapy (ECT) without the required muscle relaxant medication.
An unannounced inspection was carried out at the acute psychiartirc unit of the hospital on June 3rd and 4th 2014 .
Inspection of one individual clinical file found a detained patient had consented to a course of electroconvulsive therapy treatment.
The anaesthetist failed to administer the required muscle relaxant medication before one of the treatment sessions.
The medical record stated that the patient has complained of joint stiffness and that the consultant psychiatrist would inform the patient of the drug administration error.
“However, there was no record in the patient’s clinical file that this adverse incident has been discussed with the patient,” the report said.
At the request of the inspectors, a review report in relation to the incident was provided.
Inspectors said there was no record in the of the event entered in the incident log or reviewed by all relevant clinical personnel and the manager.
“The clinical governance in response to this incident appeared to be lax” the report said.
The Inspectorate Mental Health Services immediately requested a report on the incident from the clinical director and notified the Mental Health Commission of this “matter of serious concern”.
The report said ECT was administered on an infrequent basis at the hospital and the infrequency “underscores the importance of maintaining acceptable practice standards in the area”.
The report said the location of the unit within the general hospital and the design and fit out ”was not ideal for psychiatric care”.
All but one resident had an individual care plan and the quality of the ICPs was variable, the report said.
“In one case, a resident with dementia and behavioural problems who required nursing home care was recorded as needing counselling.”
Overall, the report said the care and treatment provided was of a good standard the unit.
Residents has access to the full range of multi disciplinary team members and there were good initiatives underway “to enhance therapeutic provision”.
However, the report found the occupational therapy room and mini-gym room remained inaccessible to residents for the third year in a row and no progress had been made in that regard.
The report said there was “inadequate recreational provision” for residents and no ring fenced staff or budget for recreational facilities.
“There were two rooms with television and there was a computer with internet access at a cost of €1.”
The report found doctors did not used their Medical Council numbers when writing prescriptions which is a requirement of the Medical Practitioners Act.
Inspectors queried an incident log which found the unit had called the gardaí to “assist in the administration of IM medication”. Inspectors were told by staff that this was policy.