Hundreds of children received “risky” treatment from a doctor working in mental health in South Kerry and significant harm was caused to 46 of them, a report from the HSE has found.
The review concerned allegations that that young people who attended mental health services in South Kerry were prescribed inappropriate medication.
The review has examined the treatment of more than 1,300 young people who attended the South Kerry Child and Adolescent Mental Health Services (Camhs) over a four-year period, The Irish Times reports.
Risks involved in the treatment included sleepiness, dulled feelings, slowed thinking and serious weight gain and distress, according to the review.
The authors, who reviewed 1,332 files, found no extreme or catastrophic harm was caused to the patients in these files. They found that not all of the children who the doctor worked with were put at risk of harm.
The review also found the care of 13 other children by doctors was also risky. The authors found proof of significant harm to 46 children.
This harm included production of breast milk, putting on a lot of weight, being sleepy during the day and raised blood pressure.
ADHD diagnosis
The review said the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) for secondary school children was often made “without the right amount of information from their teachers on how the children were at school”.
Checks for unwanted effects from the medication prescribed "did not happen", including pulse, blood pressure, and height and weight.
“These observations were not regularly checked or not recorded properly. Necessary blood tests were not always done. The doctor was not available for interview.
“We 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.”
Contributory factors the review found included the fact there was no clinical lead for the Camhs Area A Team. “This was one of the reasons for failing to provide and keep a high quality service.”
There was also no consultant child and adolescent psychiatrist from 2016 for the Camhs Area A Team.
While another consultant child and adolescent psychiatrist agreed to cover the vacant post until it was filled, it was expected this would only be for a short period.
“It took much longer than expected to find someone to fill the vacant position. Not enough attention was paid to the possible risks while this job was vacant.”
The consultant psychiatrist supervising the doctor did not see problems that developed over the following two years, 2017 and 2018.
Concerns about the doctor were first reported in 2018, but there was no evidence that these concerns were investigated.
In 2019, concerns about prescribing medication were clear, according to the report. The supervisor in charge at the time advised changes, but the recommendations were never implemented.
The doctor was working extra hours, and observed to be very tired, but nothing was done about the issue.
The review said there was no oversight of the prescribing of medications or the doctor's performance.
In 2020, the doctor was recommended for other jobs, despite concerns over the doctor's work.
After a new senior medical manager started in the service, concerns about the doctor were not passed on.
Recommendations
According to the review, the service has not put in place many of the recommendations of the National Camhs Operating Procedure 2015 or the Camhs Operational Guideline 2019.
It did not have updated treatment plans that are shared with the patient their family and the person who referred them to Camhs. It also failed to name a key worker in all cases, a team coordinator or a practice manager.
The Camhs Area A Team had a lot more referrals of new patients than was usual for other services throughout the country. Some of the referrals which were not accepted were not dealt with quickly and were left waiting for treatment.
There was no shared diary and reception staff did not know who was coming in for appointments. “Staff cannot quickly know who is working on a case. All of this means cases get lost.”
Procedure for looking after case files was not being followed.
Staff and doctors were able to take files from the file room without signing them out, which is against HSE policy.
The review said there is proof of two missing referrals and 10 full case records, this has been reported in line with data protection rules.
While the Camhs has a governance group, it did not check the facility was working safely and effectively.
The review made 35 recommendations, including:
- Children and their families should be invited to be part of the governance structure of the Camhs service.
- The recruitment of a permanent full-time clinical lead consultant psychiatrist must remain a priority for the service.
- community healthcare organisation managers in the HSE should think about setting up a working group to look at the current and future needs of Camhs.
- Training for all staff in risk and incident management. “Across Ireland, the head of the CHOs and the senior doctors should be told about the risks for their teams which have not had consultants for a long time.”
The HSE reiterated an apology to the 46 young people and their families who suffered serious harm. The apology was also extended to the 240 young people “who did not receive the care they should have”.
“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,” Michael Fitzgerald, chief officer of Cork Kerry Community Healthcare, which has responsibility for HSE mental health services in Kerry, said.
Apology
“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.”
The review team was led by an external Camhs consultant, Dr Seán Maskey, from the Maudsley Hospital in London. Mr Maskey travelled to Ireland to work on the review.
The HSE has already apologised to about 250 families for substandard care which came to light following the review.
A whistleblower who alleged substandard treatment of clients of South Kerry Camhs prompted the review.
The HSE initially looked at the files of about 50 young people who attended the service, after which it was decided to carry out a “look-back” review of all files between July 2016 and April 2021.
“We ask for the time and space to communicate directly with the young people affected, as we have done on an ongoing basis since last April when the review process began,” Cork Kerry Community Healthcare said in a statement.
“We will not be making any further comment until young people and families receive the report, other than to say that supports are in place for those affected, and that we are committed to acting on all recommendations in the report.
“Where the review identified deficits in the care of any young person, we have apologised directly and sincerely to that young person and, where appropriate, their family. We are repeating that apology in writing as part of the publication process.”
“We sincerely thank the young people and families who took part in the review process, and we do not underestimate how difficult this has been for them.”
The HSE is operating an information line for those affected, which can be reached on 1800-742 800 from 8am-8pm, seven days a week.
