TAOISEACH MICHEÁL MARTIN has told the Dáil that the report into the care of more than 1,300 children who attended the HSE-run South Kerry Child and Adolescent Mental Health Services  is a “damning indictment” of the service.

Following the publication of the report, there will now be a full audit nationwide of compliance of CAMHS.

The report, published today by the HSE, found that 46 of the children suffered “significant harm” while attending the service and that review into 240 young people showed the service did not meet the standards which it should have.

It found that 227 children being treated by a non-consultant doctor employed at the service were exposed to the risk of significant harm due to the doctor’s diagnosis and treatment of them. 

These issues included sedation, emotional and cognitive blunting, growth disturbance, serious weight changes, metabolic and endocrine disturbance, and psychological distress.

The non-consultant doctor was not interviewed as part of the review.

It also found that 13 other children were found to have been unnecessarily exposed to a risk of harm under the care of other doctors in the service.

The HSE issued an apology following the publication of the report, which was sent to the families of the children involved.

Speaking in the Dáil during Leaders’ Questions, the Taoiseach said:

The first principle of medicine is to do no harm. Children were harmed here by a complete failure of clinical performance and oversight, and the entire management of the service.

“Following the publication of the report, there will be a full audit nationwide of compliance,” he said, stating that audits will be conducted in each of the 72 CAMHS teams which will include a random selection of files, proportionate to the medical caseload, from a continuous six months of a predefined time period in 2021.

The Taoiseach said he has also been in discussions with Minister of State for Mental Health Mary Butler in the last 24 hours with a view to seeing “what more needs to be done”. He said he has an “open mind” to taking more actions.

The report “doesn’t pull any punches”, he said, stating that the report has deemed the treatment to be risky.

“It’s very important to say it’s not the parents fault,” said Martin, stating that a lot of parents feel guilty. The parents were only going with what had been advised by the treating clinician, he said. 

The review was commissioned by the HSE after concerns were raised about the treatment of a number of young people attending certain facilities. It was conducted by a team led by Dr Seán Maskey, a consultant child and adolescent psychiatrist based in London.

Maskey found “unreliable diagnoses, inappropriate prescriptions and poor monitoring of treatment and potential adverse effects” which exposed many children unnecessarily to the risk of significant harm.

Of the 1,332 cases reviewed between June 2016 and April 2021, the report says that “no extreme or catastrophic harm” was caused to these patients. 

The report details that significant harm was caused to 46 children and young people, including weight gain, sedation, elevated blood pressure and galactorrhoea, or the production of breast milk.

It says the figure of 46 is likely to change as new information becomes available from meetings with the children, young adults and parents affected.

The HSE said: “We have sincerely apologised to the 46 young people and their families, and we wish to repeat this apology publicly today.”

HSE officials and clinicians offered meetings to all 240 of the young people who did not receive the care they should have. We have apologised in writing to those affected, we apologised in person at meetings and today we sincerely repeat this apology.

“We opened an information line in April for young people and their families on 1800 742 800. The current opening hours are 8am to 8pm seven days a week.”

ADHD diagnosis

Detailing key causal factors, the report says the diagnoses of Attention Deficit Hyperactivity Disorder (ADHD), particularly for secondary school children, was often made “without adequate evaluation and without the required level of information in relation to their presentation in school from their teachers”.

Feedback from teachers was not requested as part of the management of treatment response for ADHD. 

The review also found evidence of inconsistent and inadequate monitoring of unwanted effects of medications.

Children started on stimulants and antipsychotics did not have a baseline pulse, blood pressure, height or weight measured and charted regularly.

There was “no expectation” of checking pulse and blood pressure seven days after starting a stimulant or increasing the dose. Repeated height, weight, pulse and blood pressure measurements were “erratic” and not plotted on developmental charts.

It also says GPs of patients were asked to do the blood tests in some but not all instances when children were started on antipsychotics, but there were no results of this on file in the majority of cases and the tests were not routinely repeated.

Identifying key contributory factors, the report says there was no clinical lead and no consultant child and adolescent psychiatrist for the CAMHS Area A Team, “which contributed to this failing to deliver and sustain a high-quality service”.

When concerns about the non-consultant doctor were first raised in 2018, “no effective action was evident to address them”.

It says concerns regarding prescribing by the doctor were “clearly identified” in 2019. 

The doctor was known to have been working excessive hours and to be tired, if not exhausted, at work, but this was not addressed.

There was no system to check the prescribing of medications or the quality of service by the doctor’s supervisors.

In 2020, the doctor was recognised as hardworking and “still considered an important asset to the service”. The serious concerns about them were not raised with new management in 2020.

The report says it is a reasonable assumption that the doctor was “intending to help, not harm, the patients they treated and that the exposure to risk and harms occurring were as a result of a lack of knowledge about good practice”.

Apologies

The report was commissioned by Michael Fitzgerald, Chief Officer of Cork Kerry Community Healthcare, which has responsibility for HSE mental health services in Kerry.

Speaking today, Fitzgerald said: “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. 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,” he said.

Fitzgerald also thanked the young people and their families involved in the review of the services.

“I attended some of the meetings with the young people myself, so that I could hear about the experience they had with our service first hand and also to offer them a formal apology,” he said.

The staff involved in the extensive review process have been humbled by the dignity shown by the young people and their families, by the patience they have had with the process and also by the respect they have shown for our staff. It is clear to us that we let people down and we have a lot of work to do to rebuild trust in the service, and this work has already begun.

Dr Maura Young, Executive Clinical Director of Kerry Mental Health Services, also apologised to the children.

“The publication of the review is one part in the process in rebuilding trust in the service, and we will use the recommendations from Dr Seán Maskey to improve the service and rebuild the community’s confidence in the service,” she said.

“During our meetings with young people and their families, many people asked us if there was anything they themselves should have done differently. I want to be very clear that there is nothing that any child, young person, parent or guardian should have done differently.

“You put your faith in our service, and you did not receive the service which you expected, and which you were entitled to expect. The report makes it clear that while there were many reasons for the failings, none of the fault lies with a young person or family member.”

‘Highly disturbing’

Reacting to the report, Dr William Flannery, Consultant Psychiatrist and President of the College of Psychiatrists of Ireland, said: “This case is highly disturbing, will be a cause of huge distress for families involved and personal responsibility is of course paramount here.”

“However, the specifics of this case cannot be separated from the broader recruitment and retention crisis in our mental health services at present, which is having a significant negative effect on patients.

Not only does the absence of full multidisciplinary team members affect support and care for children and their families, but an absence of consultants can lead to difficulty to adhere to governance, professional standards and inherent routine reviews which are all necessary for the safe delivery of care, especially when the service is under-resourced, understaffed and under pressure.

He added that it was “imperative” that suitably qualified psychiatrists were available to care for patients who needed them, and that it was highly regrettable that this was not the case in South Kerry CAMHS.

“Psychiatrists, as medical doctors, are specialists in the treatment, support and knowledge of mental illness and disorders as well as the broad spectrum of mental health challenges,” he said.

“The specialism requires competence and knowledge of internationally evidenced based treatments and supports that are psychological, social as well as pharmacological. CAMHS and all specialist areas of mental health services require that specialist qualification of psychiatrists and their allied health professionals to provide the best possible support and service to families.”

CEO of Mental Health Reform Fiona Coyle said the review has exposed a serious lack of clinical oversight in our mental health services.

“This has caused great distress to the children and families involved directly. It is also giving rise to concerns for children and families accessing mental health services across the country. Each and every child who uses mental health services deserves appropriate care and support,” she said.

She urged the Minister of Health to put in place a national review “to ensure that our services are complying with the highest standards of care”.

It is crucial that additional support, including advocacy support is made available to those affected. We are calling for a national advocacy service for children to ensure that the rights of children and young people accessing mental health services are respected and protected.

Chief Executive of Children’s Rights Alliance Tanya Ward said the report was “extremely concerning”.

“Significant harm has been caused to children down to lack of supervision, staffing and poor practices. It is simply not good enough that individual practice caused such a negative ripple effect to so many,” she said.

“Why did the systemic checks and balances not unearth this bad practice sooner? Why did it take a whistle-blower to reveal the truth? Children should be able to trust our mental health system in their hour of need. These families have been seriously let down and we must do all we can to fix the system so this kind of thing never happens again.”

Recommendations

The report says the South Kerry CAMHS has not implemented many of the recommendations of the CAMHS Standard Operating Procedure 2015 or the subsequent CAMHS Operational Guideline 2019.

It says the service has not appointed key workers to all cases, has not appointed a team coordinator and has not appointed a practice manager.

There is still no full-time consultant child and adolescent psychiatrist at the service.

It says the number of referrals of new patients to the service was “proportionally higher” than other services across the country, and that the number of referrals has not reduced in line with other services.

The report also says that “despite several efforts documented over the past five years by the line managers”, the Team A team does not keep a shared diary, meaning reception staff do not know who is coming in for appointments, coordinators can’t quickly identify who is working on a case, and cases are lost.

Procedure for looking after patient case files was not always followed. Staff and doctors were able to take files from the file room without signing them out, which is against HSE policy.

It says that clinical information was not always recorded in the appropriate patient record, and there is evidence that two referrals and ten full case records remain missing.

The report made 35 recommendations, including that children and their families should be invited to be part of the governance structure of the service.

With reporting by Christina Finn