Dáil Éireann debate -
Tuesday, 5 May 1992

Vol. 419 No. 1

Private Members' Business. - Mental Treatment (Amendment) Bill, 1992: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a second time."

Mr. Roche

Last week I said the objectives of this Bill were admirable. Many other speakers echoed the same sentiment. It is difficult to comprehend the horror and turmoil of wrongful incarceration. Wrongful detention in a mental institution must be akin to some Kafkaesque nightmare.

I have complimented Deputy Fennell for highlighting this particular issue. It is timely, as we have seen from a couple of recent extraordinary cases, that the issue be discussed, brought out of the shade and highlighted politically. The Bill has made progress in that it has achieved that purpose. I said also that while I believe the Bill will not go beyond Second Stage the considerable purpose will have been served in that the Minister for Health, Dr. O'Connell, has already given a clear indication that it is his intention to provide in the Green Paper for this whole area.

At the end of my contribution last week I mentioned, too, that I felt that the subject matter of this Bill was so complex and so multifaceted that it was not appropriate legislation to cover in Private Members' time. I mentioned that legislation in this area should cover many areas which, through no fault of the drafter, are not covered in this Bill. Clearly, it must cover responsibility for services, deal with the issue of designation of centres for the provision of the services, deal with the issue of licensing and the control provisions, guardianship, protection against exploitation — particularly exploitation when we move into a community care mode — the issue of advocacy and the establishment of mechanisms to vindicate rights. It strikes me that these can only be addressed in legislation produced by the Minister for Health, with the benefit of all the professional services that a serving Minister has, and also following the production of a Green Paper which the Minister has indicated he intends to produce.

The matter of admission to hospital or a psychiatric centre needs to be given far greater consideration in law than is provided for in the proposed Bill. The Bill does not, for example, address the matter of voluntary admission and its replacement by informal admission. Clearly, any new legislation must incorporate a change whereby patients can enter psychiatric services, hospitals or centres with no formality other than what currently exists in the general hospital.

As the time is short I will abbreviate some of my comments. It is clear also that the whole time element needs to be dealt with in greater details. It is important that new legislation should provide for a much shorter period for detention than the six months currently in vogue. Furthermore, any new legislation should contain within it a review period; I suggest a review period of a week and certainly not more than a month on any detention order before allowing it to become effective.

The reality is we are dealing with an extraordinarily complex area, an area that is tragically difficult to deal with it in Private Members' time. A Bill on this issue should concern itself, in greater detail than this Bill does, with the whole issue of consent for treatment. A matter of compulsory treatment for people deemed to be seriously ill and in need of such treatment but who refuse to have such treatment, will have to be the subject of review and detailed consideration. The Bill does not take cognisance of a wide range of issues which must be the subject of any proposed new legislation. These issues would reflect the considerable progress which has been made. While there are dark areas in mental treatment it is important to recognise that considerable progress has been made during the past few years.

I said at the outset of my contribution the previous day that I was pleased to be able to deal, however briefly, with this extraordinarily complex area. I said also that I have the utmost confidence in the Minister for Health who has indicated the prerequisites for resolving the difficulties. He has indicated, first, that he is conscious of the problem and, second, that he has the compassion needed to resolve it. From what we know of his character he has the will to resolve the problem. While I compliment Deputy Fennell for introducing the Bill, I am confident that we can reposit our confidence in the Minister on this issue.

Mr. McCartan

I thank Fine Gael for the opportunity to contribute to this very important debate and, in particular, Deputy Nuala Fennell for taking the initiative to draw attention to an appalling and glaring absence in the whole area of law reform, a situation that was highlighted by the unfortunate case of the woman who had been taken almost summarily into the custody of one of our mental hospitals but who was, at least, able to make contact with the outside world, convince people of her sanity and, through Deputy Fennell and others, highlight the utter inadequacies of the Mental Treatment Act, 1945, as a vehicle of protecting and ensuring the rights of people who are alleged by others to be somewhat mentally deficient.

The Mental Treatment Act, 1945, is the most outdated item of legislation relating to the general area of civil liberties and medicine in Ireland today. It is particularly significant, despite the many developments that have taken place in both the legal and medical areas, that our legislation in this area has fallen so far and so notably behind. The draconian nature of the 1945 Act is based on the idea that those with mental deficiency or handicap are considered less than human by the great majority of us. The deference paid on the other hand to the unquestioning judgment of members of the medical profession adds to the unsatisfactory nature of the provisions in the 1945 Act that have existed for far too long. These ideas were graphically brought home to me as a practising solicitor in the early seventies. One of my first cases involved — I hope the House will bear with me while I explain it — a man from the west who was lodged in the central mental hospital in Dundrum. He wrote to me and I went to see him. He explained that because of a marital disagreement between himself and his wife she had literally got to the local priest and doctor quicker than he had — not that he ever suggested he would take that avenue — and by one device or another he ended up in a district mental hospital.

There, protesting to the resident medical superintendent his innocence and sanity, he was simply ignored and spurned. As the resident medical superintendent turned on his heel to walk away, this patient picked up a stone, threw it in his direction and missed. Nonetheless he was charged with the offence of common assault, was certified by the district justice within the terms of the Act, and on a certificate of the Minister for Justice of the day, ended up in Dundrum Central Mental Hospital. That was in 1953. In 1975, 22 years later, I met that man, sane as the day he went in but, unfortunately, at that stage very institutionalised. The doctors' concern was not with regard to the man's sanity but rather with his inability to cope with the outside world should someone take the courage and the decision to discharge him. Shortly afterwards, as a result of a lawyer now showing some consideration, the case was reviewed and, within a short time, he was returned to the district mental hospital and, eventually, released into the commmunity. In the early days of his committal he challenged the whole process in the High Court, but the law of the day in reviewing it through a process of judicial review certiorari was that the strict letter of the law had been complied with. For upwards of 22 years a sane, inoffensive man was detained unnecessarily at Dundrum Central Mental Hospital, and only because of the provisions of the 1945 Act.

Shortly after, as a knock-on effect, another unfortunate man wrote to me from Dundrum Central Mental Hospital. This man, spurred by the success of his co-patient, had written to the High Court to complain that after 15 years something should be done about the fact that as a sane person he was still incarcerated in Dundrum Central Mental Hospital. This man, again, was sane and inoffensive. He was eccentric, certainly, and a person of very determined and emphatic view. The case was lost in the High Court but, on appeal to the Supreme Court, the then Chief Justice recognised that while the letter of the law had been complied with, the assertions of the man, so carefully set out in documentary evidence and almost screaming his sanity, opened up the possibility that a person, though technically and legally correctly lodged, could nonetheless challenge the medical view and use the courts as a device to do that. Again, the Supreme Court asked if I would act on his behalf. I did so temporarily but, as part of his eccentricity, he decided he would do better in the Supreme Court arguing his case without my services. Subsequently, on my election to the Dáil in 1987, I was extremely pleased to be called to the gate of Leinster House to meet this man. Though he had failed in his legal arguments in the Supreme Court, he was subsequently transferred back to the district mental hospital and released back into the community because of the initiatives he had taken. He also was as sane and inoffensive though perhaps as eccentric as the day he went in.

These two cases brought home to me that people who have been plucked from our community and lodged in a mental hospital on the certification of one or two doctors are in the worst possible position to launch a case on their behalf. It is remarkable that so little has been done over the years to review the operation of the Mental Treatment Act, 1945. There are many provisions in that Act which are totally inconsistent with our constitutional thinking and with medical opinion and practice today. It is because the people concerned are in our mental institutions and are so little regarded that so little has been done.

It is a remarkable achievement by Deputy Fennell and those who have been drawn into a broad group, to have produced legislation, however limited in the way it is expected to act, designed to challenge the 1945 Act, how it has worked since it was introduced, and highlight the need for action. To the extent that that is the purpose of the Bill, I am happy, on behalf of the Democratic Left, to support it. I committed that support in writing to Deputy Fennell on receipt of the Bill. As a mechanism to force us to address legislation that is long out of date and in need of reform, this initiative by Deputy Fennell and Fine Gael deserves the support of the House. One has to accept that this Bill may be defeated if the Government take an absolute position against it on the vote, but if the Minister for Health will give a commitment, if he has not done so, to take direct action on the issues raised it will be a good thing.

There was reference to a Green Paper or, perhaps, a White Paper on the issues. I am concerned about that because I have argued the need to bring forward a verdicts Bill to deal with insanity as an issue in the criminal justice area. If that is to be deferred to await this paper, we will have to wait longer than we expected for the legislation promised by various Ministers. Whatever about the desirability of having a major paper on this area of work, there are too many cases in which the Mental Treatments Act, 1945 is being abused in a way that we never intended. If we are not to take on board this legislation and await longer process of report and debate then the Minister must give a commitment to take decisive interim action employing whatever provisions in the 1945 legislation as are available to him. In particular the Minister should agree that the inspector of mental hospitals be given adequate resources and a directive to carry out an overview of all patients now in the Central Mental Hospital and in district mental hospitals that are a cause for concern.

The legislation is particularly welcome and must be fully considered. It presents an opportunity that must not be missed. The constituency of the mentally handicapped or deficient, of the people who are in our mental hospitals, is so marginalised that it is rarely a Deputy, particularly from the Opposition, has the opportunity to bring forward reforming legislation on their behalf. It is almost akin to the position of aliens in Ireland who are so poorly treated by Government and administrative officers. Again, the prospect of ever developing any movement within this House to bring forward legislation to establish a proper administration procedure for dealing with aliens coming to these shores is so unlikely because they are such a marginalised constituency. The same applies to the mentally handicapped and for that reason I would be slow to allow this legislation to slip lightly away from this Chamber on the basis that the issue will be looked at in due course by Government. It needs a more specific and stronger commitment than that.

The legislation is brought forward to deal specifically with two phenomena. The first is the use of the Act as a device to take people into custody in extraordinary circumstances and in circumstances never contemplated by the Act. Those are the type of short term actions taken in classic family rows or marital disputes where the certificate of a doctor — or doctors — is required for the purpose of committing someone to a psychiatric hospital.

The first point I want to make refers to a more general matter, the very curious provisions of the 1945 Act, which say that if the patient is being taken to a private hospital there is a need for two doctors to sign the commital form but that if the patient is being taken to a public hospital, only one doctor need sign. The very clear discriminatory provision in that Act is based on the fact that a private hospital will be receiving well off "private" patients and that public hospitals are for the poor. It is a remarkable class discrimination written into the 1945 legislation which has survived for so long, despite our Constitution and its provisions.

It is an invidious discrimination which, in any amending legislation, should be addressed; Deputy Fennell proposes to do that in her legislation as, from now on, two doctors will be needed to sign the form. However, I do not believe that in her legislation there is a requirement that at least one of the doctors should be someone employed or appointed by the Minister of the day with specific expertise to assess these types of cases, as provided for in the 1983 legislation in England. It is something which should be addressed so that one doctor is not supporting another colleague at the same level or in the same discipline or practice. It is very important to have one perhaps from the community in general practice and the other a doctor with psychiatric or specific training and expertise who can professionally assess the correctness of the procedure.

In regard to the proposals in the Bill dealing with the abuse of the situation which exists — which is all too common and continues to this day — of using the 1945 Act as a device to resolve interfamily disputes or marital problems, the first phenomenon I mentioned, the legislation proposed by Deputy Fennell, argues for the setting up of a review board. There is a fundamental difference between the process of reviewing and the process of appealing against a decision. In a review you are simply asking a higher authority to survey what has gone before and to decide whether it was correctly dealt with on the facts available to the original people who made the decision. However, in an appeal process, you are moving to a higher authority and you are entitled to look for an entirely new decision based on additional or new evidence and on an entirely new process or hearing.

In any legislation dealing with this issue I would much prefer to see a process of appeal in place as opposed to a process of review. In fact, some of the later provisions in the Bill circulated by Deputy Fennell seem to suggest that, while she is legislating for a process of appeal, she calls it a process of review. That is particularly suggested by the provisions in section 6 which entitle the review board to make separate types of orders from those originally given, to release a person where they are not happy with his or her commital and to allow for the hearing — orally or otherwise — of the review process. The importance of an appeal is that a person is entitled to be present, to be represented, to call additional evidence and witnesses and to be heard on his or her own behalf. That is not the established law in a process of review but it could be dealt with on Committee Stage of the Bill and rectified. It is really only a matter of terminology in the Bill, as opposed to anything in principle, which would divide Deputy Fennell and myself.

I have some reservations about the period of time provided for by way of review. If the legislation is specifically seeking to provide a vehicle for tackling the kind of situation which led to Deputy Fennell outlining the case of the unfortunate woman, which was so well documented in the media and in this House on the Adjournment and in other debates, a period of one month is extremely long to enable action to be taken by the review board. I would have thought that a person complaining that he or she had been summarily taken from home, workplace or other area and committed to a mental hospital and who was protesting his or her sanity should be entitled to be heard within a matter of days — if not hours — rather than the period of one month provided for in the Bill.

Certainly different considerations arise with the second phenomenon, that of the longer stay patient who has been in a district mental hospital for over one year or thereabouts where the Bill argues for a systematic review of all these cases. In that case a period of one month would seem to be reasonable but I suggest to Deputy Fennell that she should shorten the period provided for in her Bill. I do not think there could be any objections if the principle and idea is that we should not tolerate the abuse of this type of legislation to take people unwarrantedly and summarily into custody on medical grounds. They should be entitled to an immediate review or appeal.

Because of the quasi-judicial nature of the process suggested, there is also a need to reaffirm in this or any legislation that it is not a substitute for the provisions of habeas corpus which exist in the broader law. There is also — and should always be — the right of a litigant to go directly to the courts if he or she decides to do so. There may be occasions when it is much more appropriate to get the sanction and protection of the court rather than simply relying on an internal review procedure. That is something which should be provided for. I say that not just simply as a throwaway consideration; there is a body of law developing on the administrative, natural justice side within our courts which says that if there is an avenue of redress administratively within the authority, a hospital, school, university or union, the courts tend to deny the review procedures of the courts in favour of exhausting the internal remedies first. However, habeas corpus is a very important right and should always be available to a patient or a person in custody in addition to or over and above any administrative internal arrangements.

Because of the vulnerability of the people in hospital, we should also provide in any legislation for the establishment of duty solicitor schemes in relation to each of the hospitals. This can be very easily provided for and established in consultation with district Bar associations and district associations of the solicitors' profession. In every county or region in which there is a district mental hospital there is a readiness by solicitors to work on a duty rota system, in consultation with the Department of Health, to provide an immediate panel of lawyers who can be contacted on behalf of a patient to say that he or she requires legal advice and assistance and to ask for a lawyer. Mental hospitals have very high walls and are terribly remote places. Unfortunately, communications from them tend to be ignored or put aside on the basis that they are from people who are less than human things. That is why a duty solicitor scheme is very important, it should be established if not legislated for.

One of the provisions in the Bill argues that non-family persons who seek a review can only do so at the discretion of the review board. I suggest that a rider be attached to the effect that the discretion only be exercised for good cause. Perhaps the discretion should be taken away entirely. A person can be wrongly committed following internal family rows. The person committed might not have within the immediate family someone who would come to his or her aid. It is important that there should be an outside person, a friend perhaps, who should not have to show good cause and who would have the same rights to come in as a family member.

Section 6 provides that the board would not be entitled to release a person unless satisfied that the person would not be a danger to his self-interest or a danger to the community. This is very close to the provision in the British legislation. If a person is wrongly lodged in the first place, he or she should be entitled to be released provided that the review board consider him or her mentally fit. The fact that the person concerned might on release assault the person responsible for having him sent in is not a matter that should be borne in mind. A person could have a huge grudge against a spouse or other family member perceived as having been responsible for having him or her put into hospital in the first place and it would be a matter for the criminal code to deal with any such assault. If a person is of sound mind, that should be the only criterion with regard to release.

I welcome the provisions dealing with people who are detained unnecessarily for inordinately long periods. It is important that there be a systematic review by an independent body. Under the 1945 Act that work is supposed to be ongoing by the Minister for Health through the inspector of hospitals. From my experience of visiting mental hospitals, patients are not aware of that. They are totally at sea, not knowing that there is an authority looking after them and taking an interest in them.

The legislation is a valiant effort to highlight an area of major oversight by our legislators. That oversight is rooted directly in the problem of peripherality and isolation which is the constituency of mental hospital inhabitants. A very good opportunity is presented by this Bill. The 1945 Act is grossly outdated in many of its concepts and ideas. It is incumbent on us as a matter of urgency to legislate in this area. For those reasons my party will support this Bill on Second Stage and we commend Deputy Fennell on her initiative.

Dr. O'Hanlon

I propose to share my time with Deputy O'Donoghue.

An Ceann Comhairle

Is that satisfactory? Agreed.

Dr. O'Hanlon

I compliment Deputy Fennell on bringing forward her Bill. It is very timely because it gives the House an opportunity to discuss the 1945 Mental Health Act. The input to the debate will be useful to the Minister in his onerous responsibilities in the coming months.

We all accept that the 1945 Act is outdated in terms of dealing with the admission of persons against their wishes. The case Deputy McCartan first instanced would suggest that in his opinion it was outdated in 1953, within eight years of its passage through this House.

It is important that there should be a legal framework for the development of community psychiatry, which did not exist to any great extent in 1945. We would all have to be very concerned at the wrongful detention of any person in a psychiatric hospital or elsewhere and the purpose of this Bill is to deal with that. It is also important to keep a balance. We do not want to frighten people outside who find themselves in need of psychiatric treatment in a hospital. We must not give the impression that something is very seriously wrong there and that their rights will not be attended to. In my experience as a medical practitioner and in the Department of Health the number of complaints about admission was small.

Consultants in the psychiatric hospitals have very rarely seen people admitted who did not need admission. It is important to recognise that of the people who go into a psychiatric hospital, 80 per cent do so voluntarily. Of those who go into hospital involuntarily, 80 per cent are out within six months. The number of people going into hospital for longer than six months is very small. In St. Davnet's, a major psychiatric hospital in the Cavan-Monaghan area, ten patients were admitted for longer than six months in 1991. It is expected that at least two thirds of those will be back living in the community within two years. Nowadays there is nothing like the position which obtained some years ago when patients admitted to psychiatric hospitals might spend the rest of their lifetime there.

We are all concerned that there should ever be a wrongful admission or a wrongful detention. There is a major responsibility on everybody concerned in the admission of a patient to a hospital against his or her wishes. There is a major responsibility on the applicant, on the general practitioner who makes the recommendation and on the consultant at the psychiatric hospital. If a medical practictioner were wilfully to sign a recommendation and a reception order against the interests of the patient, that would bring on the doctor the wrath of the Medical Council and probably erasure from the medical register.

It surprised me that Deputy Fennell when dealing with admission to hospital dealt only with the recommendation. This legislation would require that two doctors should sign the recommendation, but there is no reference to the person signing the application. Deputy Fennell cited the case of a husband who signed an application to have his wife committed to hospital a week after she had secured a barring order against him. The fault in that instance lay with the applicant. The reform of legislation in this area should begin with the application. Perhaps an applicant should declare any issue that might bring undue influence, that might be a source of undue influence or be perceived to put undue influence on the decision to be made.

On the question of whether two applicants rather than two general practitioners should be required to sign an application for involuntary admission into a psychiatric hospital, it seems to me that whether the signatures of one or two general practitioners should be required is not particularly at issue. Deputy McCartan and Deputy Fennell have pointed to a wide variation in what happens in major urban areas as compared with rural areas. In rural areas it is generally the family doctor who would sign the recommendation for admission and the family doctor, or any other doctor from the area who might be standing in for him or her and would know the people concerned and their background. The kind of occurrences described by Deputy Fennell and Deputy McCartan would as a result be highly unlikely to arise in rural areas. The Minister might therefore consider the question of applications, the way in which they are signed and whether there are any factors that might bring undue influence or might be perceived as constituting undue influence on the part of the person making the application. A reception order is signed by a consultant psychiatrist, who has seven days in which to sign such an order. That time might be shortened. A case might be made for the issue of a reception order as soon as a patient arrives at a psychiatric hospital, which order would be valid for only 72 hours, when it would be reviewed by the psychiatrist, who would issue a further order if that were considered necessary.

It is a matter of major concern to each and every one of us that no one should be wrongfully detained in a psychiatric hospital. At the same time, it is important that there be procedures in place whereby a person who does need to be detained in a psychiatric hospital, either in the interests of protecting themselves or in the interests of protecting other members of the public, might receive the necessary care effectively and expeditiously. Of course we have to be careful that we do not create an environment in which people could be admitted or detained wrongfully in a psychiatric hospital but it is important to keep a balance. Society expects that. We would not be thanked if we were to bring forward legislation that would prevent persons who were a danger either to themselves or to others from being detained in an involuntary way if that was necessary.

I agree with the comments made last week by the Minister and the Minister of State in relation to mental health review boards. It is desirable to have mental health review boards in place but it is important to carefully examine the kind of review board to be put in place. Under Deputy Fennell's Bill a review board would consider the position of a patient only on the application of a relative. I believe that the provision should be much broader that anybody would have access to a review board and that all patients should be reviewed from time to time. We have to conform with the European Convention and with United Nations regulations. Legislation adopted should also specify who would be involved in a review board. I consider that a review board should constitute a psychiatrist, perhaps a legal person and a lay person. In time, the review board would review all patients. Deputy Fennell's Bill would result in a review being made only on the application of a relative but that would not conform with one of our obligations under the European Convention. We must guard against introducing legislation that would prove to be unsatisfactory and therefore never be implemented, as happened in 1981.

Section 9 places an obligation on the senior psychiatrist in a hospital to provide the patient with all of the documents when an order is made. While I agree that the principle of this provision is desirable, such a measure would not work. First, the psychiatrist would need to take account of the patient's mental capacity.

At the time of such an order being signed, many patients would not be in a position to understand what was happening. In my view, it is not practical to implement legislation that would provide that on the signing of a reception order patients had to receive into their hands documents relating to their admission to and detention in a hospital. Another point worth mentioning is that if all of the documentation were to be handed to patients as soon as they went into hospital, people outside might be deterred from making an application. None of us wants an application made that might wrongfully detain a person — and, as I have said, that is a very rare occurrence — but at the same time we do not want a situation to develop in which relatives in particular will not sign an application in the instance of a person needing to be admitted to hospital because they are afraid of the paper being handed to the patient and the patient taking redress on release from hospital. There is a very real danger that such a situation could develop, and I am sure that Deputy Lee would agree with me on that point. While I agree with the principle of section 9 that a patient should be entitled to all of the information necessary, the provision should be studied very carefully before being written into legislation.

At column 1847 of Volume 418 No. 7 of 28 April 1992 of the Official Report Deputy Fennell said:

People with mental health problems are regrettably the poor relations of the health services. Mental health has a low priority in terms of budgetary or monetary planning. There is a great need for broad-based reform which would concentrate on reducing overcrowding in our institutions, developing community facilities...

I do not agree with Deputy Fennell that mental health in any way has a low priority in terms of budgetary or monetary planning. The document Planning for the Future, published in 1984, was the first major report on any area of the health services in the eighties. Other reports, such as the report on the elderly and the report on persons suffering from mental handicap, followed that publication. I pay tribute to Mr. Barry Desmond that that report was prepared in his time in this House. It was the first of many reports. That does not suggest that mental illness is low on the list of priorities, it suggests that it was very high on the list of priorities in the early eighties.

No discipline in health care has developed to the extent that psychiatric treatment has in the last 25 years. Modern drugs have dramatically changed the pattern of management of mentally ill patients. Deputy Fennell refers to the need to develop community services. We can be proud of the extent to which we developed our community services in the eighties at a time of financial constraint. The Department and the health boards were responsible for drawing up development plans and those plans were initiated, and many of them were implemented throughout the country. In 1958 there were 22,500 patients in psychiatric hospitals and at the end of 1991 there were 7,800 patients. That is a dramatic reduction. No other area of health care has changed so dramatically in a generation and has been so beneficial to the public, particularly those who are mentally ill.

It is important to look too at developments in psychiatric services in hospitals. Many acute psychiatric patients are now treated in our major general hospitals. New major acute psychiatric units have been established in such hospitals as Cavan, Tralee, Rocommon, Naas and so on. It is encouraging to see the old Victorian building which was the psychiatric hospital in Sligo being sold to be used as a hotel. It is encouraging also to see that the Grey building in Cork has been closed. There have been major developments in the hospitals and in the community facilities. There has been the development of hostels, day care centres and workshops.

An area which needs to be looked at and which was touched on by Deputy McCartan, is a relationship between psychiatric hospitals and the Central Mental Hospital. The dividing line between guilt for crime and psychiatric illness is very thin. I am sure we all know people in prisons who we feel should be in psychiatric hospitals and vice versa. There is an area there where I would like to see patients from rural areas being treated in their own psychiatric hospitals rather than in the Central Mental Hospital.

Another area at which the Minister should look is escorting patients, particularly violent patients, to psychiatric hospitals. I commend the Garda for their co-operation but they are constrained to an extent by the 1945 Act in that they can only transport a patient for detention for longer than six months, which is totally against the modern trend. The Minister should look at that.

While I agree with the sentiments expressed by Deputy Fennell in her Bill, the Bill is defective. It is not far-reaching enough and it is not comprehensive. It is in the best interests of the patients for us to wait for the Minister's Green Paper and discuss it. Knowing the Minister, I have no doubt that he will bring legislation before the House expeditiously.

Mr. O'Donoghue

I compliment Deputy Fennell for bringing this matter before the House and the Minister for his reasonable response. I hope the Minister's response will be reciprocated and that in the final analysis Deputies will understand that a Green Paper to address the matter in a far-reaching way is very necessary.

Up to relatively recently the care of psychiatrically ill patients was Victorian — there were Victorian buildings the length and breadth of the country which were never suited to caring for psychiatrically ill people. A couple of years ago when the inspector for mental hospitals visited Our Lady's Hospital in Cork which housed psychiatrically ill patients, he was appalled at the standard of the building. He was appalled when he saw what were obviously rodent droppings in the rooms, the state of the building in general and that human beings should be obliged to live in such conditions. This was not just true of Our Lady's Hospital in Cork, it was also true of other psychiatric institutions.

To a large extent, what is hidden from the public eye is often forgotten, and what is not seen is not spoken about. This is one of the major reasons I compliment Deputy Fennell for bringing this matter before the House and the Minister for the consideration he has given it.

In recent years we have made considerable progress in caring for psychiatrically ill patients, but that is not to say there is not a very long way to go. The document "Planning for the Future" represents the first genuine progress in the care of the psychiatrically ill here in this century. Day care centres have been opened throughout the country to care for people in their own communities. This kind of futuristic thinking was lacking up to recently. A human being is entitled to the environment in which he or she can be most comfortable. In the care of the psychiatrically ill, except in extreme cases it would be fair to say that the fairest way to treat such people is within their communities where they can integrate with people they know, doing things daily in places with which they are well acquainted. Locking people away in large institutions, in large concrete jungles, was never and could never be a recipe for addressing a psychiatric illness.

I feel strongly that the proposals of "Planning for the Future" will not work unless the problem of sheltered employment is addressed urgently. Irrespective of the state of a person's health, but certainly when a person is psychiatrically ill, there is need for an occupation. In many cases it will not be possible or feasible for people residing in hostels around the country, in day care centres, to be fully occupied, a fact to be regretted. In the day hostels established nationwide to date there had been a certain degree of success in that patients accommodated there are fully occupied daily, returning to their hostels in the evening, another category of patient who would best benefit from sheltered employment. Indeed, the matter of sheltered employment will have to be addressed by some Government, and the sooner the better, if we are to care adequately for the psychiatrically ill in our community. I contend that implementation of the proposals contained in the document "Planning for the Future" will not succeed unless adequate sheltered employment is guaranteed.

One matter which distresses me enormously, which should have been addressed many years ago and which must be addressed now, is that of accommodation for adult mentally handicapped persons. It is very wrong that, as we approach the end of the 20th century, mentally handicapped people, with nowhere to go, should be housed with psychiatrically ill patients suffering an altogether different disability. To say the very least it is Victorian, in this day and age, that there should be such an inadequate supply, indeed shortage, of accommodation for our adult mentally handicapped. Knowing that he has the capacity to do so, it is a problem I should like to see this Minister address urgently. Funding will have to be found for the provision of this type of accommodation. If we do not succeed in doing so we shall be failing in our social duty in this respect, as has been the case since the foundation of this State.

In that context it would be remiss of me not to refer to the outstanding work being done daily — 365 days a year — by the Rehabilitation Institute of Ireland. Their singular unique contribution to the training of mentally handicapped people is very often not recognised for what it is. I know that very many people with a disability have been assisted back into the community by the Rehabilitation Institute of Ireland. Such people have been reintegrated into the community, their dignity intact, because of the training provided by that institute. Their role in Irish society should be lauded for the wonderful thing it is.

In general terms by way of progression of the proposals contained in "Planning for the Future" I should like to see established a system of sheltered employment in the community, a continuing shift from institutionalisation, so that people with mental illness may live, indignity, in places with which they are well acquainted. I sincerely hope that the good work begun under the auspices of the document "Planning for the Future" will continue. It would be my hope also that we will continue to remove patients from long-stay accommodation and buildings, more relevant to an age long past.

Dr. Lee

I congratulate Deputy Fennell on having introduced this Bill, she alone having been the standard bearer for psychiatric patients' civil rights since 1972. Successive Ministers for Health, and, in the main, Ministers for Health of the present Government, have been totally remiss in safeguarding or defending the civil rights of psychiatric patients. Indeed, in the course of his remarks in the House on 28 April 1992, the present Minister admitted that when he said the following about one of his departmental inspector's report:

Some of the conditions described by the inspector were extremely disquieting and should have no place in a modern day health service.

I will repeat that because it is a most significant statement on the part of a Minister for Health:

Some of the conditions described by the inspector were extremely disquieting and should have no place in a modern day health service. What was even more disturbing was the fact that in so many instances the level of service provided fell so far short of the standards one would reasonably expect to see in place.

The Minister continued to say:

I accept that the excuse for some of this was due to resourcing difficulties — a very fancy phrase "resourcing difficulties"— but the standards of accommodation and quality of service varied so greatly that much of it cannot be blamed simply on lack of resources.

I should like to put that statement into plain, ordinary language that people on the street use. "Resourcing difficulties" sounds nice but means simply a lack of finance. I will endeavour to further define that phrase and describe them as the Fianna Fáil cutbacks for which the Minister at long last accepts responsibility. It has not happened so far in the history of this Dáil of which I am aware but the Minister, judging from his remarks, is now accepting responsibility. It is another example of the evolution under the present Government of a most unchristian, uncaring attitude to the most vulnerable members of our society, our fellow brothers and sisters in psychiatric hospitals.

We have not yet seen the Minister's Green Paper on Mental Health. In addition, I saw no mention in the Minister's contribution of a charter for mental hospital patients.

Minister for Health (Dr. O'Connell)

It will be included; it has already been prepared.

Dr. Lee

I hope it will be. I heard the Minister speak recently about a charter for patients in general hospitals. It is much more important that patients in mental hospitals, many of whom are deprived of their basic civil rights, should have a charter in this day and age and I would respectfully ask the Minister to consider its provision. I call on the Minister, first, to establish this charter for mental hospital patients, with a judge to research complaints, second, to establish a system of complaints and, third, to establish a system of investigation——

Dr. O'Connell

It is there already.

Dr. Lee

——the same judge to draft the charter to include the proviso that the aim of the hospital and the duty of all staff be to service the needs of patients at all times; in this case the paient must be paramount, providing for a mandatory censure and, if necessary, prosecution of all errant staff by the relevant health authority. There must be a proper complaints procedure which will deal with complaints about staff, conditions and treatment. Fourth, I should like the charter to provide for the establishment of an inspectorate of mental hospitals to replace the present inspector of mental hospitals post. The chairman of the inspectorate should be a lawyer or an ex-judge while the investigator should be a member of the Garda Síochána or a person who has experience of carrying out investigations. The inspectorate should also include members of the medical profession — consultants, general practitioners and community psychiatric nurses, and any other back-up staff required.

Fifth, the charter should insist that organs cannot be removed from patients either living or dead. No psychiatric patient, with or without his permission, should be subjected to experimental drug trials. Sixth, nurses in mental hospitals should be recruited — this is open to debate — from nursing staff in general hospitals who wish to specialise in this branch of medicine. I accept that this is probably a matter for An Bord Altranais under the auspices of the Minister. Nevertheless, I should like this provision to be included in a charter for psychiatrically ill patients.

Seventh, nurses working in the mental hospitals system should, on a regular basis, be able to take one year's break to work in a general hospital. Eighth, non-political visiting committees who would have 24 hour inspection rights to all areas of mental hospitals should be set up. These committees should be of short term duration, lasting one to two years, and should be recruited from various interested bodies and by way of press advertisements. At present many members of visiting committees are political appointees. The present visiting committees who have responsibility for visiting psychiatric hospitals and overseeing mentally handicapped services are, in part, made up of political appointees and comprise 12 members of the Eastern Health Board.

The Minister has not yet made public the inspector's report for 1988-89. Even though this scandalous situation did not evolve under the Minister's stewardship, he has to accept responsibility for it. One can justifiably ask why is this the case? This report has not been made public. Why has there been a three year delay in publishing the 1988-89 inspector's report on the mental hospitals? It seems extraordinary that this situation should have been allowed to evolve. One can also justifiably ask if there are cases in this report which are grossly damning of the psychiatric hospital services. From the best information available to me, I believe part of the inspector's 1990 report was made public last June at a meeting of the Eastern Health Board. Much of that report dealt with the psychiatric hospitals in Dublin and contained alarming information.

Trainee gardaí and prison officers should spend at least four weeks working in psychiatric hospitals as part of their training. I have called for this measure before both inside and outside this Chamber which I am certain will save lives in Garda or prison cells at a later stage as many members of the criminal fraternity have mental, drug, drink and social problems. More voluntary groups should be encouraged to work on a voluntary basis in psychiatric hospitals. Psychiatric patients need to meet people other than hospital staff. They also need to be treated in a more friendly environment, a home atmosphere, and need to be in normal surroundings. The volunteers who visit these hospitals could include non-violent prisoners, FÁS trainees, personnel from the Army, Navy or Air Corps, women's associations, men's associations and religious groups.

As a general practitioner and community doctor, I welcome Deputy Fennell's Bill. I have first hand experience of the shortcomings, trauma and heartbreak which mental illness causes. It is perhaps the most insidious of all illnesses; it is certainly one of the most difficult illnesses to treat. Many mental patients are in their prime, they are physically perfect. We are all familiar with the picture of chronically depressed patients sitting in a room looking into space, oblivious to all around them. While they may seem to be in good physical health I can assure Members that they are not. We are all familiar with the unfortunate patients with a psychiatric disorder who run amok in the community and are a danger to themselves, their families and the community and who are committed to psychiatric hospitals under temporary restraining orders. We are also too familiar with the problems caused by the 1945 Mental Treatment Act.

Her article in today's Irish Press entitled “Philomena's Story” gives an account of a tragic story. This unfortunate lady tells about how she was forced into a psychiatric hospital. She had no history of psychiatric illness or alcohol related problems. She was committed to a psychiatric hospital against her will. It would appear that she was committed solely on the false claims made by her husband. This is one of the problems caused by an inadequate and unamended Act. Murphy's law states that if it can happen it will happen. Unfortunately, it happened in this instance. The 1945 Mental Treatment Act has been described today as internment without trial. That is an inflammatory definition of that Act. A new pressure group called Wrongfully Institutionalised People — WIP — have called on the Minister to establish a review system for the victims of the 1945 Act. They have urged the Minister to adopt, as an interim measure, Deputy Fennell's Bill pending the introduction of a new mental health Bill.

The public at large do not realise that when a person is compulsorily committed to a psychiatric hospital he loses many of his civil rights. In many cases, when they are discharged having been successfully treated, they become productive members of society on whom their families depend but because of this committal they experience many social difficulties.

Life insurance is very difficult to get, bank loans are virtually impossible to obtain, as are credit cards, if one wants them. They experience severe problems with passports and visas, a loss of friends due to the social stigma and, last but not least, perhaps the most profound stigma, poor credibility in the family law courts — that applies to males and females.

Another example which typifies the serious shortcomings of the Mental Treatment Act, 1945 is documented in today's Irish Press and gives a balance to the story. It refers to a young man in his 30s who was committed as a result of allegations by his wife and brother-in-law after he consulted with her family about her drinking problem. He is now receiving psychiatric treatment for problems caused by the electric shock treatment he received while involuntarily committed. The Minister must urgently amend the 1945 Act. In fairness to the medical profession these cases are the exception rather than the rule. Such loopholes as exist in the law must be closed off urgently.

In recent days I have had extensive consultations with other general practitioners and doctors in the psychiatric services and we have no problem with a built-in requirement for two qualified doctors to sign the temporary commmittal form, Form No. 6, about which there has been so much talk. On the first page of that form the person's name, address, age, sex, marital status, religion and occupation must be filled in. There is a separate section for committal whereby the applicant must state relationship to the person whom he wishes to commit, whether it be husband, wife or relative — it must be a blood relative rather than an in-law. There is a section on the form where if no relatives are available somebody else may apply for a committal order, for example, the community welfare officer. On the reverse of the form is the section which is the cause of so much controversy, the requirement that there should be the signature of one doctor. It is a simple, straightforward form to complete. Part III, which refers to the order for reception and detention, is very important and it states:

I have considered the above application and certificate and I hereby order that the said person be received and detained in the mental hospital named in Part I of this form as a temporary patient and as a chargeable patient.

Signature: . . . . . . . . . . . . . .

Person in charge of the hospital or an officer of the hospital authorised to make a temporary chargeable patient reception order.

There are various notes and conditions attached to that form.

The form which relates to private patients is virtually the same, but two doctors must sign this form. It also contains a section on order for reception and detention of the patient. To put into context this whole matter of the signature of one doctor for a public patient and two doctors for a private patient one must go back to the time the Act was introduced in 1945. At that time it was decided that for many reasons — for example, geographic remoteness — it would be virtually impossible to find two doctors who would be in a position to examine a mentally disturbed patient. For example — I hope the people from the various parts of the country that I mention take no offence — if a patient in Connemara west, the remotest end of the Ring of Kerry or the Fanad peninsula, needed to be urgently admitted to hospital for treatment it would be impossible to find two general practitioners to sign the form. Hence the requirement for a single signature. We should remember that this Act was introduced in 1945 after the war when petrol was in short supply and there were very few motor cars. That is why only one signature was required.

I further suggest that at two o'clock in the morning in a remote part of the country it would still be almost impossible, to obtain two GPs to certify the patient. A patient who is extremely disturbed, agitated, violent and a danger to himself and to those endeavouring to calm him will, in these circumstances, be denied vital, early and urgent treatment because of a loophole in the proposed Bill. A balance must not be lost.

When a patient is admitted to hospital he or she must, under the Act, be examined by the person in charge of the hospital or an officer of the hospital authorised to make a temporary chargeable patient reception order. This means in practice that the consultant or the senior registrar on duty must examine the admitted patient within 12 hours before that person is certified as an in-patient.

I would remind the House that these doctors are highly trained medical personnel. Nowadays in practice consultants and senior registrars list on the chart — indeed, this must be the practice for all future committals — the reasons they must make this order absolute — for example, chronic and severe depression, danger to the person concerned or to his or her family, severely mentally disturbed or possible suicide. This practice must be made mandatory. It will be another fail-safe mechanism. No person, least of all a doctor, is perfect. We all make mistakes, but we must learn from them. I reiterate that we in the medical profession have no difficulty in agreeing to amending the Act to provide that two doctors must sign the form.

In conclusion, the psychiatric service is the poor relation of the health services the "fag-end" of the caring service. It gives me no great pleasure to say that the Department have neglected the psychiatric services. Commonsense, that rarest of commodities, will demand that this Act should be updated. It is the Minister's responsibility, and it behoves him as a medical practitioner, to do this, and I am sure he will.

I congratulate Deputy Fennell on bringing forward this Bill and on the work she put into it. Most speakers have given due recognition to her efforts in this regard. The legislation dates back to 1945 and I believe everybody will agree that since then there has been great change in attitude towards mental health. I know Deputy Fennell is fully au fait with the developments regarding the policy document, Planning for the Future, which was introduced in 1985. If we are to address the area of mental health and give due recognition to changing attitudes and changes in mental health since 1945 we will have to introduce very wide-ranging legislation. The previous speaker referred to the Minister's speech of Tuesday, 28 April, in response to the Bill. He read a couple of specific lines and I would now like to focus on one or two of those sentences.

Debate adjourned.