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CAMHS report: Taoiseach says report is ‘damning indictment’ of mental health service

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The review into the care of young people in South Kerry CAMHS has been published.

The review into the care of young people in South Kerry CAMHS has been published.

The review into the care of young people in South Kerry CAMHS has been published.

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Taoiseach Michéal Martin has said the report into the alleged overmedication of young people who attended South Kerry Child and Adolescent Mental Health Services (CAMHS) is as a “damning indictment’ of the mental health service

Speaking in the Dáil today, following the publication of the report which found that 240 children did not receive the standard of care they should have and found proof of significant harm to 46 children, he said “children were harmed” by the service. 

In light of the report Mr Martin has said that a nation-wide review of  all Child and Adolescent Mental Health Services must take place. 

"The first principle of medicine is to do no harm. Children were harmed here by a complete failure of clinical performance oversight and of the entire management of the service. In my view this demands a fundamental review, not just in South Kerry, but overall of the situation pertaining to CAMHS.”

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He described the report as ‘shocking’ and ‘very very serious’ 

The review carried out by the HSE looked at a total of 1,322 files. However, the review also found that there were missing files, with proof of two missing referrals and 10 case files. Concerns about the doctor in question were first raised in 2018, and no proof was found that these issues were addressed. 

The treatment by the doctor placed 240 children at risk, the report concluded, and the HSE has apologised to these children. Their families are primarily spread across South Kerry.

The review centred around young people who attended the service between July 2016 and April 2021. 

In a statement, the review team led by external CAMHS consultant, Dr Seán Maskey, from the Maudsley Hospital in London, who travelled to Ireland to lead this newly published report, 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.

“The report also details that significant harm was caused to 46 children and young people, including weight gain; sedation; elevated blood pressure and galactorroea (the production of breast milk). We have sincerely apologised to the 46 young people and their families, and we wish to repeat this apology publicly today,” the HSE said. 

“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.”

The review further found that checks or observations of unwanted effects of medications did not happen or were not recorded properly; these related to matters such as pulse readings, blood pressure and height and weight measurements. 

The doctor at the centre of the controversy was not interviewed for the report, but the HSE has stated “they 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 Consultant Child and Adolescent Psychiatrist supervising the Doctor did not see problems that developed throughout 2017 and 2018. In 2019, concerns about prescribing medication were clear. The supervisor at the time advised changes but did not insist that these happen. The report states that if a review had been done sooner, problems may have been noticed. 

A key contributory factor was the absence of a clinical lead for the CAMHS Area A Team, the HSE said.

The report has made 35 recommendations to be implemented to prevent this happening again including hiring a Clinical Lead Consultant Psychiatrist.

Sinn Féin TD Pa Daly said this morning the CAMHS report is "shocking".

"The CAMHS Report, published today, is shocking and far worse than anything I could have imagined,” he said. “It exposes everything that is wrong with our health service and the complete lack of services available for young people. In the case of CAMHS, it is clear there was no oversight of this doctor or the service itself.

"Of particular concern is that when concerns were initially raised, they were not addressed. I am pleased that Michael Fitzgerald, Head of Cork Kerry Community Healthcare and the HSE, has accepted the findings of the report.

"Now the recommendations must be implemented without delay.”


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