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13 people using mental health services in Carlow, Kilkenny and Tipperary took their own lives

The state’s mental health watchdog has found training for mental health service providers was inadequate.

Image: Shutterstock

THE MENTAL HEALTH Commission has published a report into mental health services in Carlow/Kilkenny and South Tipperary, arising from a number of deaths and other incidents between January 2012 and March 2014.

During this period, 13 service users died by apparent suicide. There were also incidents including the death of the relative of a service user, service users suffering burns, serious episodes of self-harm while resident in a crisis house and a serious physical assault by a service user on a member of the public.

The commission decided in March 2014 to instigate a process called ‘targeted intervention’: a review, an implementation plan for recommendations and a follow-up inspection to verify that required actions have been taken.

The report found that “adequate assessment of suicidality might have alerted clinical staff to the risk of suicide”. It noted that training for risk assessment was either insufficient or wasn’t being applied in all cases.

However, the report states there is no basis to suggest the rate of apparent patient suicide in the catchment area was anomalous. It is comparable proportionally to the rate in the UK.

At the time of the review (early 2014) newly presenting 16 and 17-year-olds in South Tipperary were not receiving a safe, adequate service. There was a practice of transferring residents from the unit at the hospital to community residences to free up bed space.

‘Deep disharmony’

The report also found there was a “lack of cohesion” and “deep disharmony” between senior management and the medical consultants that had “undermined clinical governance”.

Commenting on the review John Saunders, Chairman of the Mental Health Commission, said: “During this process we identified a number of significant issues and the commission takes the view that a fundamental cultural change is required which can largely be implemented within the system that has been created by the new reforms within the region.”

This cultural change must foster a shared understanding of putting the patient first. Healthcare is dependent on people, not machines, and openness, candour, compassion and transparency are key to ensuring a quality mental health service which does put the patient first.

The targeted intervention team made 19 recommendations. A subsequent inspection and correspondence with the service established that 12 of these recommendations have been implemented, with implementation of the other seven underway.

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Junior minister with responsibility for mental health Kathleen Lynch welcomed the publication of the report.

“I have been aware, for some time, of concerns around the issue of suicide or other incidents in the area. I supported the original decision to make this targeted intervention and I wholeheartedly support objective measures which promote quality and safety for service users who are at the centre of everything we do,” Lunch said.

Samaritans 116 123 or email jo@samaritans.org
Console 1800 247 247 – (suicide prevention, self-harm, bereavement)
Aware 1890 303 302 (depression, anxiety)
Pieta House 01 601 0000 or email mary@pieta.ie – (suicide, self-harm)
Teen-Line Ireland 1800 833 634 (for ages 13 to 19)
Childline 1800 66 66 66 (for under 18s)

Read: ‘It was a normal day, then I saw a man about to take his own life’

Read: ‘Just by being there for a friend, we can keep life itself’

About the author:

Órla Ryan

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