St. Lukes Report, June 2009

Adjournment Debate – Dail Eireann – The Report of the Committee of Inquiry to Review Care and Treatment Practices in St. Michael’s Unit, South Tipperary General Hospital and St. Lukes Hosptial, Clonmel – Thursday 25th June 2009 – Introduced by Dan Neville TD, Fine Gael Spokesman on Mental Health and President of the Irish Association of Suicidology.

Deputy Dan Neville: I am thankful to have the opportunity to raise the report of the committee of inquiry to review care and treatment practices in St. Michael’s unit, South Tipperary General Hospital, Clonmel and St. Luke’s Hospital, Clonmel included in the quality and planning of care and the use of restraint and seclusion, and to report to the Mental Health Commission. I will deal with one small but important area of the comprehensive and detailed report.

The clinical risk manager reviewed fractures recorded in St Luke’s Hospital, Clonmel from July 2002 to 31 January 2004. The regional risk manager calculated that, at the time of the September 2004 report, the risk of residents of St. Luke’s Hospital or St. Michael’s unit sustaining a fracture was between two and three times higher than the average risk of residents of the other psychiatric hospitals in the region.

The fractures in Clonmel were of small bones in hands and feet and fractures to the upper end of the humerus differed from the number and type of fractures seen in the other units where fractures of the hip and wrist are as a result of falls from bed and falls on an outstretched hand. The report referred to the fact that most patients are cared for in wards which are permanently locked and where there is restriction of movement. A number of patients are elderly frail and vulnerable. The report stated:

There is a lack of rationale for combining patients with different diagnoses i.e. patients with challenging behaviour and frail patients. The resulting patient mix means that some patients are at risk of injury from other patients.

It is a cause of concern that this review highlighted many other incidents of fractures occurring in these specific patients in the past. In some situations, old fractures or healing fractures were identified coincidently on X-ray. The report went on to state that a worrying observation made during the course of this review was that in 18 of the 19 incidents involving fractures the documentation states that they were not witnessed. In the remaining one, it is unclear whether there were any witnesses.

Two of the 19 residents each had fractures on two occasions during the 18 month period and five of the residents suffered earlier fractures.

A retrospective examination of the charts of the patients of St. Luke’s Hospital showed that in many cases there was no documented supporting history of injury, trauma or signs or symptoms to account for the previously undiagnosed fractures. On 15 July 2005, a meeting of senior managers and clinicians was held to consider the report. The meeting was not minuted. Many of those attending were unclear about the authority of the meeting. At the meeting the regional risk manager outlined the findings of the report and indicated that there was a strong possibility of non-accidental injury. The possibility of informing the Garda was considered. The need for further investigation into the causes of the injuries and the very high proportion of unobserved injuries was discussed and generally agreed. However the matter was not reported to the Garda and no effective action was taken on foot of the risk manager’s report.

No minutes of the meeting were kept or circulated and no follow-up meeting was arranged. Those attending the meeting expected it would lead to the development of an action plan for the implementation of the recommendations of the report but discussion about how this would be achieved, whether through further investigation or a review of clinical and organisational practice, was not concluded.

The Mental Health Commission inquiry report makes the following observations in regard to the investigation into the fractures: “Taking into account the lack of further investigation following the September 2004 report, the limited implementation of its recommendations and the extreme slowness of the process, the inquiry team considers that the safety and welfare of residents was not given the highest priority.” The inquiry team believes that, where the safety and welfare of residents appears to be at risk, prompt action is required. Further investigation to clarify the level of risk and implementation of measures aimed at reducing the risk is necessary. The inquiry team believes that the lack of urgency of the process following the September 2004 report, the lack of further investigation to clarify the level of risk to residents and the failure to implement many of the report’s recommendations indicate that the safety and welfare of residents was not given the highest priority. The inquiry team believes that this was probably influenced by industrial relations problems, a concern to avoid bad publicity and potential for distress.

Patients and their families should feel safe and when one considers that only one of the 19 injuries uncovered in September 2004 was witnessed by the staff, it is of great concern. The failure to refer the matter to the Garda following consideration smacks of a cover up. The risk of sustaining a fracture in St. Luke’s hospital was between two and three times higher than that of the local psychiatric hospital which highlights the seriousness of the level of injury. The welfare of the patients continues to be of concern and will only be satisfied by the closure of the hospital and the transfer of patients to modern hospital conditions.

This hospital was recommended for closure because of the conditions. I have only referred to a section of the report, which contains details of the conditions which prevail but we do not have time to go further into the detail today. If these conditions applied to any other group of patients, there would be a three hour debate in the Dáil on the matter.

Deputy Mary Hanafin: I thank Deputy Neville for raising this important matter, to which I will reply on behalf of my colleagues, the Minister for Health and Children, Deputy Mary Harney, and the Minister of State at the Department of Health and Children, Deputy John Moloney.

The report made for very difficult reading, highlighting significant deficiencies in the mental health services in Clonmel. The Minister of State, Deputy Moloney, requested that I mention that the publication last April of the report on St. Luke’s and St. Michael’s represented one of his lowest points since he was appointed Minister of State for with responsibility for equality, disability issues and mental health.

To put the report into context, in June 2007 the Mental Health Commission established an inquiry under section 55 of the Mental Health Act 2001 to review care and treatment practices in St. Michael’s Unit, South Tipperary General Hospital, Clonmel, and St. Luke’s Hospital, Clonmel, including the quality and planning of care and the use of restraint and seclusion.

The inquiry was established in the light of concerns regarding services in Clonmel which had been identified in several annual reports of the inspector of mental health services. The report found that individual, person-centred care was not at the heart of the system in Clonmel and this was attributed to staffing and environmental constraints, as well as outdated practices. The report also pointed to a lack of clear leadership and a shared sense of purpose and concluded that the safety and welfare of residents had not been given sufficient priority.

While the Government fully accepts the findings and recommendations in the report and readily admits that aspects of the service provision described in the report are totally unacceptable in a modern mental health service, the publication of the report demonstrates the robustness of the Mental Health Act 2001, the independence of the Mental Health Commission and the importance of its role in safeguarding the standards and quality of care in the mental health services. It is clear the systems put in place by the 2001 Act to promote high standards and good practices in our mental health services are working. Unacceptable standards and practices can no longer be swept under the carpet and tolerated; deficiencies must and will be addressed.

In terms of Clonmel, the Mental Health Commission and the HSE have held several meetings on the implementation of the report’s recommendations. It is anticipated that a detailed project plan for the development of the mental health services in south Tipperary, which will be time bound and have clear lines of responsibility for implementation, will be finalised in the coming weeks. I am informed that the Inspector of Mental Health Services will monitor closely the HSE project plan and report to the Mental Health Commission on a regular basis. The Mental Health Commission has now attached conditions under the Mental Health Act 2001 to the continued operation of St. Michael’s and St. Luke’s as approved centres.

Since the Mental Health Commission’s inquiry team visited Clonmel in autumn 2007, progress has been made in making service users partners in their own care, providing more services in the community, reducing hospital admissions and providing more home-based treatments and outreach services.

In line with the recommendations for the closure of the old psychiatric hospitals in A Vision for Change, it is proposed to close St. Luke’s in 2010. The closure will take place on a phased basis with wards closing sequentially and the hospital can only finally close when the clinical needs of the remaining patients have been addressed in more appropriate settings. However, I am satisfied that plans are well advanced for the complete closure of the hospital by December 2010. I understand some wards have already closed and the number of residents in the hospital has reduced. A further two wards are due for closure this year. All current residents will be provided with care in more appropriate settings as identified through multi-disciplinary assessments, in partnership with the residents and their families and carers. Also, as wards close, staff will re-deploy to community-based teams which will further enhance services in the community.

The focal point of modern mental health services is the community and developing a community-based service is the way forward. To that end, extended hours services are now available in both Cashel and Clonmel, providing more accessibility. The extension and renovation of the Morton Street Day Centre has been completed and is availed of by more than 20 service users daily. Such initiatives whereby supports are provided in the community will, it is anticipated, greatly reduce the need for hospital admission and will help service users to achieve meaningful integration and participation in community life.

I assure the House that the Government continues to be fully committed to the improvement of mental services, not only in Clonmel, but throughout the country, through the implementation of A Vision for Change. The deficiencies in the services in Clonmel have been identified and these deficiencies will be addressed by the HSE and closely monitored by the inspector of mental health services.