Minister for Health James Reilly has described as “totally unacceptable” the failure to record and explore all sudden deaths by suicide.
Dr Reilly was commenting on a HSE mental health audit on the notification and investigation of incidents of sudden, unexplained deaths of persons in community mental health services.
The report of the audit completed in January found that incidents of sudden, unexplained deaths of people in community mental health services were not being notified in accordance with HSE policy and procedures and most of those being investigated did not conform to the “systems analysis methodology”.
The Minister said the HSE was acting to ensure the detailed recommendations the report made on the notification, recording and investigation of sudden unexplained deaths were implemented.
Memorandum
A memorandum was issued in March to relevant managers, re-emphasising the requirements in dealing with such deaths.
Dr Reilly was responding in the Dáil to Fianna Fáil TD Colm Keaveney who said that fewer than 25 per cent of the incidents involved in the investigation were notified in accordance with the law “and half of the incidents investigated did not provide for a review with respect to the deaths involved”.
Mr Keaveney said “largely there is no standardised approach within the service” and there was no evidence to suggest that an operational plan was developed, subsequent to establishing an investigation.
“If we are to learn anything from the crisis within the country with respect to death by suicide we need to establish where the systems are breaking down within the HSE.”
The Minister said he could assure the deputy that the 18 recommendations were being put in place.
He said he took the issue extremely seriously and he pointed out that it was through such investigations and reviews that “we find out if there is an unintended consequence from some of the treatments that some of our patients take”.
“This is what came across years ago with one particular drug which was causing cardiac arrhythmia problems. Had it not been investigated and the issues recorded, it would never have come to light.”
