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Mental Health

CAMHS report raises serious concerns about children on medication not getting follow-up care

Some children and adolescents seeking mental health treatment are not getting appointments for up to two years, a new report has found.

A LARGE NUMBER of children and adolescents seeking mental health treatment don’t receive necessary follow-up care, a new report has found.

An interim report into an independent review of the provision of Child and Adolescent Mental Health Services (CAMHS) in the State has found that many children and young people end up “lost” in the system.

In one catchment area, there were 140 “lost” cases within the local CAMHS team.

Some children and young adults who should have had follow-up appointments via CAMHS – including for review of prescriptions or monitoring of medication – did not have an appointment for up to two years.

In certain cases when people turned 18, there was no planning, discharge or transition to adult services.

Some people also didn’t receive any advice about medication, or get follow-up appointments for review of prescriptions or monitoring of medication.

The interim report, authored by the Inspector of Mental Health Services, Dr Susan Finnerty, was published by the Mental Health Commission (MHC) today.

Dr Finnerty decided to produce an interim report due to “the serious concerns and consequent risks for some patients” that were found across four out of the five Community Healthcare Organisations (CHOs) that have been examined so far.

She has called for “urgent and targeted action” to be taken to address these risks.

Her review found that in one CHO alone, there were 140 “lost” cases within the CAMHS team.

Nine CHOs across Ireland provide a broad range of services that are provided outside of the acute hospital system and include primary care, social care, mental health, and health and wellbeing services.

Serious issues with CAMHS services in south Kerry were highlighted in a separate report in January 2022. Prior to that, Dr Finnerty was already scheduled to carry out this wider review.

Through her analysis, she also found evidence that some CAMHS teams were not monitoring antipsychotic medication, in accordance with international standards (there are currently no Irish national standards).

Consequently, some children were taking medication without appropriate blood tests and physical monitoring, which is essential when on this medication.

‘Inefficient and unsafe’

The review also identified “significant deficits” across many HSE teams and CHOs.

These include team members working beyond their contracted hours, often without compensation, and evidence of stress and burnout in a significant number of team members.

CAMHS staff members “worked extremely hard within the often-limited resources to try to provide a good service to the public”, the report states.

The review also found that the “lack of governance in many” areas is “contributing to some inefficient and unsafe CAMHS services, through failure to manage risk, failure to fund and recruit key staff”.

In addition, the review also found long waiting lists, unacceptable variations in care, a lack of capacity to provide appropriate therapeutic interventions, lack of emergency CAMHS services, staff shortages, and a lack of ICT systems, among other issues.

Dr Finnerty has issued two immediate recommendations to the HSE and the Minister for Mental Health, Mary Butler:

  • An immediate clinical review of all open cases in all CAMHS teams, with particular focus given to identifying and assessing open cases of children who have been lost to follow-up and physical health monitoring of those on medication
  • That the Minister for Mental Health ensures, as a priority, that there is immediate regulation of CAMHS, under the Mental Health Act 2001

The inspector has made five escalations of risk to the HSE due to her “serious concerns for the wellbeing and safety of children”.

Maskey Review

The stark findings in Dr Finnerty’s report come a year after a review into CAMHS services in South Kerry.

The review, carried out by Dr Sean Maskey, found that the care received by 240 young people in the area “did not meet the standards which it should have”.

The Maskey Review, published by the HSE in January 2022, found that 46 of the children suffered “significant harm” while attending the service.

It also found that 227 children being treated by a non-consultant doctor employed at the service were exposed to the risk of significant harm due to the doctor’s diagnosis and treatment of them.

These issues included sedation, emotional and cognitive blunting, growth disturbance, serious weight changes, metabolic and endocrine disturbance, and psychological distress.

The HSE apologised to the young people and their families at the time.

youngchinesewomanwearingjeanjacketstandingisolatedongrey File photo Shutterstock / Viktoriia Hnatiuk Shutterstock / Viktoriia Hnatiuk / Viktoriia Hnatiuk

In today’s review, Dr Finnerty also identified another team that had open cases of children where there was no documented review for up to two years. However, this risk had not been identified by this particular CAMHS service.

Another team was attempting to identify an unknown number of cases that had been lost to follow-up care after a change in staffing.

Other teams had commenced a six-monthly review of their open cases following the Maskey Review, the report notes.

‘Lost’ cases

The CAMHS team working in the area where 140 “lost” cases were identified had already started reviewing these files prior to the Dr Finnerty’s work commencing.

In the interim report, she notes: “At the time of the inspection we found that actions taken were minimal, did not involve face-to-face assessments of the child and it was unclear at what stage these children would be re-assessed.

“Further information supplied subsequently to our review from the HSE stated that a resulting Healthcare Record Review Report is currently being compiled and will be examined by the Serious Incident Management Team (SIMT) in line with the HSEs Incident Management Framework.

“The SIMT will identify if any further review is required.”

The review also uncovered that, in relation to another team, the previous consultant psychiatrist had left without re-allocating their caseload.

In this case, the team was “trying to identify which of these children required follow-up”.

Another team did not follow-up with their patients for up to two years, despite these children being on continuing medication.

Concerns over children’s welfare

Responding to the review’s findings, John Farrelly, Chief Executive of the Mental Health Commission (MHC), said the interim report “shows clear failings of governance and oversight with no evidence that a national coordinated approach is being taken to caring for children with a mental illness”.

Our core concern should be for the health and welfare of these children and the priority now for the HSE must be identifying and safeguarding the children “lost” to follow-up.

“The Inspector of Mental Health Services has advised the HSE to commence an immediate clinical review of all open cases in all CAMHS teams, with particular focus given to identifying and assessing children who have been lost to follow-up and physical health monitoring of those on antipsychotic medication.”

The HSE and the Department of Health have been furnished with the interim report.

Farrelly added: “I can confirm that the HSE CEO has committed that the HSE will immediately conduct a review of all open cases.

“This review, we have been reassured, will include a focus on physical health monitoring of children who are on antipsychotic medication as we have recommended.”

A spokesperson confirmed that the HSE received a draft version of the interim report in late 2022 and “at that time took the actions necessary to address issues raised in relation to individual service users”.

Commenting on the review, Damien McCallion, HSE Chief Operations Officer, said the report “comes at a time when we have a major CAMHS improvement process underway, and we will be putting a senior clinical/operational team in place to drive and support that process”.

“This interim report, as well as the current prescribing review and other ongoing HSE audits in CAMHS, combined with the service improvement work underway, will all contribute to this process.

The report makes systemic findings and conclusions, as well as highlighting concerns about the specific care provided to some children.

“The HSE engaged with the Inspector of Mental Health Services in the course of her work and where specific concerns were identified, we immediately put in place targeted actions plans to address them.

“In the case of all children where concerns have been raised by the MHC in their report, these have been managed directly by the service caring for them,” McCallion stated.

Direct contact with parents 

Dr Siobhán Ní Bhríain, HSE National Clinical Director Integrated Care added that CAMHS is “critically important to many young people and their families”.

Ní Bhríain noted that a key recommendation of this interim report is that the HSE undertakes a review of cases within the CAMHS service that remain open.

These are cases where a young person remains in the service but has not been seen for six months with a particular focus on physical health monitoring for those young people who have been prescribed neuroleptic medication.

The HSE is putting the necessary plans in place to carry out this review so that we can be assured that children and young people in our service are receiving appropriate and timely care reflective of their current and future needs.

“We will arrange further clinical follow-up for any child where that may be required from this review and will make direct contact with parents or guardians as necessary,” she said.

A spokesperson for the Department of Health told The Journal that the Minister of State for Mental Health and Older People, Mary Butler, has noted the interim report’s findings.

In a statement, Butler said: “Following on from several meetings to discuss the Maskey Report earlier in the year, I asked the Mental Health Commission to expand the remit of their thematic report to take cognisance of the Maskey Report which had been recently published.”

The Fianna Fáil TD also said she acknowledged the serious concerns highlighted.

“On-going and extensive engagement between my Department, the HSE, and the Commission regarding the findings of the interim report continues to take place.

“It is essential that the review of open cases takes place to ensure that all children and young people are receiving the appropriate care they need. I would like to thank all CAMHS staff for their cooperation with the Mental Health Commission and the HSE as they carry out these important audits and review.

“Acknowledging the serious concerns raised in the report, I would like to remind all CAMHS service users and their families that many of the findings relate to specific instances for some children and young people.”

Butler added that the HSE Live service is available to support any children, young people or families with concerns arising from the interim report (Freephone: 1800-700-700; Monday to Friday 8am to 8pm and Saturday to Sunday 9am to 5pm).

At this stage of Dr Finnerty’s work, a review five out of nine Community Healthcare Organisations have been completed.

These are:

  • CHO 3 (Clare, Limerick, North Tipperary/East Limerick);
  • CHO 4 (Kerry, North Cork, North Lee, South Lee, West Cork)
  • CHO 5 (South Tipperary, Carlow Kilkenny, Waterford, Wexford)
  • CHO 6 (Wicklow, Dun Laoghaire, Dublin Southeast)
  • CHO 7 (Kildare/West Wicklow, Dublin West, Dublin South City, Dublin Southwest

The following four CHOs are in the process of being reviewed:

  • CHO 1 (Donegal, Sligo/Leitrim/West Cavan, Cavan/Monaghan)
  • CHO 2 (Galway, Roscommon, Mayo)
  • CHO 8 (Laois/Offaly, Longford/Westmeath, Louth/Meath)
  • CHO 9 (Dublin North, Dublin North Central, Dublin Northwest)

The inspector’s final report is due for publication later this year.

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