Mental health services ‘struggling’ to meet standards

The Mental Health Commission has expressed concern over what it has described as a continued failure of mental health services to comply with minimum standards.

Last year the commission found that a number of acute inpatient centre providers, particularly the Health Service Executive, were “struggling” to meet minimum regulatory standards in key areas like staffing, care planning, risk management and premises.

Lower standards of compliance in these areas are associated with negative experiences for patients and staff and are not compatible with a human rights-based approach, according to the Chief Inspector.

In his first annual report since taking up the role at the Mental Health Commission, Professor Jim Lucey called for a targeted funded strategic investment programme in the public mental health system.

The MHC inspected all 66 registered approved centres last year, and while “a small number of approved centres” achieved 100% compliance with the 31 regulations, there was a deterioration in overall levels of compliance levels with legal requirements, according to the report.

Overall, the compliance rate of 85% last year was a decrease on the 88.37% figure reported in 2022.

Privately operated centres continued to achieve higher rates of compliance than centres which were operated by the HSE, according to the Mental Health Commission.

It found that the trend of non-compliance in approved centres was “going in the wrong direction”.

The low rates have been linked to a history of poor governance, inadequate investment levels and an outdated regulatory framework long overdue for revision.

“In reality, governance and management has not kept pace with patient needs, expectations and rights,” it has stated.

In 2023, 18 approved centres with instances of non-compliance received a critical risk rating.

Ninety-four serious reportable events (SREs) were reported to the MHC last year involving 30 approved centres. That is a rise from 51 serious reportable events (SRE) in 2022 which involved 23 approved centres.

Worryingly, the highest reported SRE category was ‘Criminal Events’, which is sexual assault (42 reported); followed by ‘Environmental Events’ which relate to a serious disability associated with a fall (24 reported).

Patient Protection Events resulting in sudden/unexplained deaths or injuries resulting in the serious disability of a person who is an inpatient/resident accounted for 11 SREs.

58% of SREs reported by approved centres related to female residents and the average age of a resident who was the subject of an SRE was 51 years of age.

The youngest resident was 15 years old and the oldest was 92 years.

There was an approximate decrease of 9% in the number of reported episodes of physical restraint last year. The report says there were 2,570 episodes involving 884 residents in 53 approved centres notified to the MHC.

Use of physical restraints

However, the Child and Adolescent Mental Health Service (CAMHS) sector reported the highest number of physical restraints, accounting for 19.77% of all reported episodes last year.

In 2023, Prof Lucey’s predecessor, Dr Susan Finnerty, published a ground-breaking report into the functioning of CAMHS in Ireland which led to much public discussion.

In the latest report, Prof Lucey has stated that he “does not propose to go into further commentary about CAMHS at this stage”, however he noted that he had not received new powers of inspection or regulation yet.

“However, I look with hopeful anticipation to the prospect of new mental health legislation. This legal provision has been long promised. I continue to believe that it will address the evident issues.”, he said.

Due to the unavailability of CAMHS beds, children and young people in crisis may be left with the unacceptable ‘choice’ between an emergency department, general hospital, children’s hospital, or an adult inpatient unit.

The report has noted that the number of children being admitted into adult units has reduced in recent years.

In 2023, there were 14 admissions to 11 adult units in 2023, compared with 20 admissions to 11 adult units in 2022.

A spokesperson for the MHC has said the commission has continuously highlighted that the admission of a child or young person to an adult setting is not acceptable and risks traumatising the young person further.

He said the MHC “follows up” with all service providers where there has been a child admitted to an adult unit and the provider is required to give assurance plans to avoid recurrence.

“Service providers have put effective plans in place to ensure they have access to CAMHs beds and, as a result, these admissions are continuing to drop according to the Watchdog”, he said.

‘Significant investment’

In response to the MHC’s Annual Report, the HSE welcomed the acknowledgement that there had been “a continued positive trend” in some key areas that the MHC monitors.

“We acknowledge the key role of our HSE colleagues in the mental health teams across the country who have enabled these improvements.”, it said.

In a statement it said there had been significant investment in the area over the last three years but acknowledged there were areas that needed further improvement.

It said HSE Mental Health is developing a detailed plan in response to the findings which will be informed by “engagement” with the Health Regions.

According to the statement, “work programmes” are underway to deliver recommendations within Sharing the Vision and the action plan is due to be completed and shared with the MHC in July.

Decision Support Service

2023 was the first year of the Decision Support Service (DSS) which was established under the Assisted Decision-Making (Capacity) Act 2015.

While it is part of the Mental Health Commission it has a separate role.

The DSS is for people who face difficulties and need support exercising their decision-making capacity which may include, but is not limited to, people with an intellectual disability, acquired brain injury, mental health difficulty or dementia.

It also includes all people who want to plan for a time when they might lose their capacity.

Its annual report says the registration team managed 3,145 calls and responded to 724 email queries from service users to assist them with their queries in seeking to register arrangements.

During 2023, the DSS received 25 complaints.

Four related to decision supporters or decision support arrangements made under the 2015 Act and 21 related to an attorney appointed under the 1996 Act.

On 31 December 2023, there were eight ongoing investigations according to the report, one complaint was at the screening stage, eight complaints were screened out, four were discontinued, one was withdrawn, and three were completed with findings of not-well-founded.

Of the eight complaints screened out, seven were screened out because there was no active arrangement in place, and one was screened out because the arrangement was invalid.