Two clinicians who spearheaded the campaign against the re-location of St. Michael’s inpatient psychiatric unit from Clonmel to Kilkenny in 2012 have described a Mental Health Commission report into the cluster of deaths by suicide of service users in the region as “flawed and inaccurate”.
Dr. Alan Moore, a consultant psychiatrist who retired at the end of 2011, and Professor Paud O’Regan, have called on the South Tipperary public not to allow other acute hospital departments to close and appealed for any further threats to dismantle South Tipperary General Hospital to be met with the “greatest possible energy and resolve”.
In a statment, the HSE say they welcome the Mental Health Commission report and say recommendations in it have already been acted on.
The two members of the Save Our Acute Hospital Committee said the long overdue report makes a number of findings and includes a list of recommendations, but unfortunately omits key elements including the attempts by senior clinicians to signal their concerns, and also attempts to normalize suicide rates in the service catchment area of Carlow/Kilkenny/South Tipperary.
The Mental Health Commission released their report, which was prompted by the death of 13 service users between January 2012 and March 2014 in the service catchment area of Carlow/Kilkenny/South Tipperary and following the forced closure of St Michael’s inpatient unit in Clonmel in June 2012.
Both Dr. Moore and Professor O’Regan were involved in the campaign unleashed after the sudden HSE decision announced in January 2010 to relocate inpatient psychiatry services from Clonmel to Kilkenny. They were joined by clinicians, local general practitioners, service users and families and local representatives.
“The campaigners knew the folly, and the risks to service users which this relocation would cause, and said so over and over again” they said.
Dealing with a reference in the Mental Hospital Commission report to a deep divide between St. Michael’s consultants and senior management, the two opponents of the closure of St. Michael’s said the report did not examine the nature of this disharmony, including the many attempts by the doctors to alert both managers and the Commission itself to their concerns.
“The decision by the doctors to withdraw from the clinical governance process is portrayed as a causal factor in the tragedies, whereas in reality these clinicians made a decision to withdraw from the governance process because it was flawed and ineffective and in doing so they had alerted all the relevant authorities,” they stated.
Dr. Moore and Professor O’Regan said the report made reference to premature discharge and bed shortages in the Kilkenny unit following the closure of St. Michaels, two of the very elements which were repeatedly highlighted in the earlier campaign to save the Clonmel unit.
They want what has happened in this mental health service to be investigated forensically.
“Otherwise valuable lessons will be lost, and future concerns may not be raised because of fear and disillusionment by clinicians and members of the public.” they said.
In a statement the HSE welcomed the Mental Health Commission’s report into Carlow/Kilkenny/South Tipperary mental health services.
The HSE stated it had already implemented a plan to address the reports 19 recommendations which broadly address-
Improvement to assessment and audit of suicidality, update of risk assessment processes, improved supervision of clinical staff to support good practice, consultant-led and multi disciplinary home based treatment team, review of unexpected deaths and untoward incidents, engagement with all governance processes, standardised policies on clinical and operational, improvements in communication between staff, service users, and families.
During a follow-up inspection by the MHC, they found that 11 recommendations were completed, 7 were partially completed, and one was not completed, which has subsequently been addressed. The investigation team does not recommend that any further inquiry be established in CKST Mental Health Service.
“The welfare and well being of the HSE’s service users is our priority. Many of the report’s recommendations have already been implemented and focus continues to be on delivering a high quality, reliable and safe service for all our patients. As part of the change programme in CKST mental health services, the Executive Management Team (EMT) of the CKST mental health services changed significantly in 2014. There were a number of appointments made including a permanent Area Director of Nursing, a General Manager, an Acting Executive Clinical Director, a new Services Manager and Principal Social Worker. The team has focused on addressing the recommendations of the report, and this work has been recognised and supported by the Mental Health Commi sion” the HSE said.