Damning report on patient care after wave of suicides
Published 22/07/2015 | 02:30
Thirteen mental-health patients, who took their own lives over two years, were not adequately assessed for the risk of suicide, a damning report by a watchdog will reveal today.
If the patients of mental health services in Carlow, Kilkenny and south Tipperary had been properly checked for the risk of suicide, clinical staff may have been alerted to the potential tragedies.
The highly critical report follows an investigation by the Mental Health Commission into the deaths and other serious incidents in the region between January 2012 and March 2014.
It also included the death of a relative of one of the patients. In another case, a patient suffered serious burns in St Luke's Hospital, Kilkenny.
Two patients self-harmed, while another carried out a serious physical assault on a member of the public.
The findings reveal:
At the time of the review, during the first quarter of 2014, teenagers aged 16 and 17 who were new patients were not receiving a safe or adequate service.
There was deep disharmony between medical consultants and managers, so the service was undermined.
Patients were transferred from the psychiatric unit in the hospital to community homes to free up beds, with one being moved at 3am. Two days earlier the patient had been described as "unwell and vulnerable".
However, the report found there was no basis to conclude that the number of apparent suicides was particularly high and said the rate was proportionally comparable to the UK rate.
The commission's chairman, John Saunders, said it acknowledged that the service suffered under-staffing, with vacancies and reliance on locum doctors.
He warned that the disengagement of senior doctors from governance of mental health services must never be tolerated and must be "acted upon speedily" to ensure that patients get safe and recovery-orientated care.
Three patients in the hospital died by apparent suicide. Another discharged themselves against medical advice and took their own life within hours. Self-harm led to serious burns for another patient and three suffered fractures during falls.
In the case of three patients who died within hours of discharge, one had no record of having been assessed by a doctor in the previous 72 hours. In another case a patient was discharged without his family being told.
Three patients suffered fractures after falls in the hospital's psychiatric unit but there were delays of up to four days before they were sent for X-rays.
The probe found inconsistencies in how information about tragic incidents was shared.
One doctor relied on text messages from colleagues to learn about deaths.
Another doctor had to submit a Freedom of Information request to secure a review report on a patient's death.
Mr Saunders said the commission not only carried out the review but also drew up an implementation plan, with a follow-up inspection to verify if the changes have been made.
Twelve of the recommendations have been implemented and the other seven are under way.
Mr Saunders welcomed the HSE's new process for examining patient deaths more promptly, adding that "openness, candour, compassion and transparency" must gain traction in mental health services.