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 has found.
The review into allegations that young people who attended mental health services in South Kerry were prescribed inappropriate medication was published by the Health Service Executive on Wednesday morning.
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 risks involved in the treatment by the doctor included sleepiness, dulled feelings, slowed thinking and serious weight gain and distress, according to the review.
Having reviewed 1,332 files, the authors of the report found no extreme or catastrophic harm was caused to the patients in these files.
Not all of the children who the doctor worked with were put at risk of harm, they found.
The care and treatment of 13 other children by other doctors was also risky, the review has found, and 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.
Enumerating the key causal factors behind events, 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 of observations of unwanted effects of medications “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.”
The review also identified key contributory factors including 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.”
In addition, there was 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 that it would only be for a short while.
“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 throughout 2017 and 2018.
Concerns about the doctor were first reported in 2018, but no proof was found that these concerns were addressed after being reported.
In 2019, concerns about prescribing medication were clear, according to the report, and the supervisor at the time advised changes but did not insist these happened.
The doctor worked extra hours and was observed to be very tired at work, but this issue was not addressed.
There was no system used to check the prescribing of medications or the quality of service by the doctor’s supervisors, the review states.
In 2020, the doctor was recommended for other jobs even though there was concerns about the doctor.
And while a new senior medical manager started in the service, the concerns about the doctor were not handed over to this person.
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, nor did it 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 other areas across the country, and this had not reduced at the same rate as other services.
Some of the referrals which were not accepted were not dealt with quickly and were left awaiting on a decision of acceptance.
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.”
Rules on looking after case files were not being followed properly. Staff and doctors were able to take files from the file room without signing them out, against HSE policies on the management of health records.
In addition, clinical information was not always recorded in the patient file.
The review said there is proof of two missing referrals and 10 full case records, which have been reported in line with data protection rules.
While the Camhs has a governance group, this did not check it was working safely and effectively, or talk about the risks of a long term vacancy.
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.”
Responding to the review, the HSE repeated earlier apologies it has made to the 46 young people and their families who suffered serious harm, and to all 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.
“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, who travelled to Ireland to carry out this work.
The HSE has already apologised to about 250 families for substandard care identified in the review.
The review was prompted by concerns expressed by a whistleblower in the health service who alleged substandard treatment of clients of South Kerry Camhs.
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.
Diagnosis and notes
The review, which was conducted by a team led by Dr Seán Maskey, a consultant child and adolescent psychiatrist based in London, examined allegations of inappropriate prescribing of medication as well as issues around the diagnosis of patients and missing notes. It is also expected to deal with resource issues at the service.
The report was being posted to affected families on Tuesday, and a copy has been sent to Minister for Health Stephen Donnelly.
“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.
Apology repeated
“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 – 1800 742 800 – which is open from 8am to 8pm, seven days a week.
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