Dáil Éireann Debate, Wednesday - 14 May 2014
4. Deputy Colm Keaveney asked the Minister for Health the actions he has taken following the findings of recent audits into the compliance of the notification and investigation of incidents of sudden, unexplained death of persons in community mental health services with legislative requirements and Health Service Executive policy and procedures; and if he will make a statement on the matter. [21599/14]
View answerThe audits referenced in the question highlight that there are 18 recommendations. Will the Minister share with the House what action plans he will put in place with respect to the recommendations set out in the audits? For the benefit of the House, the audits involve an investigation into community and mental health services, into approved centres and into the community setting which deal with the compliance or the non-compliance of obligations to report to the Mental Health Commission where, tragically, death by suicide by a person within the mental health services takes place. I appreciate that is not entirely preventable within the mental health service. However, it is essential that we get to answer this question if we are to learn anything from what we would regard as the greatest public health crisis in the country, which is death by suicide.
It is important that mental health services, as with all parts of the health service, are subject to periodic review or audit where issues of potential concern are identified. Such review processes facilitate services to improve the quality and safety of the care and treatment provided, by identifying any matters of concern and making recommendations as to the steps necessary to address these.
In 2013, as part of its patient safety and quality process, the HSE Mental Health services and Quality and Patient Safety Directorates requested an audit of compliance with regulatory requirements and HSE policies and procedures in relation to the notification and investigation of incidents of sudden, unexplained deaths of persons in community mental health services.
The HSE audit report was completed on 15 January 2014. The report concluded that, based on the information submitted, the audit team could not provide assurance that incidents of sudden, unexplained death of persons in community mental health services were being notified in accordance with HSE policy and procedures, nor could it provide assurance that incidents of this nature were investigated using the systems analysis methodology.
The audit report made a series of detailed recommendations in relation to the notification, recording and investigation of sudden unexplained deaths of users of mental health services. The HSE is taking steps to ensure that each of these is addressed. In March 2014, the national director of mental health services issued a memorandum to all relevant managers, re-emphasising the requirements in relation to the reporting of sudden unexplained deaths. Work is under way in conjunction with the Mental Health Commission in respect of two recommendations. The Executive is also working to ensure that the other shortcomings identified are addressed through appropriate performance management and service improvement processes.
I share the Deputy's concern and I find this totally unacceptable. Sudden deaths should always be recorded and explored. This is how we find out if there is an unintended consequence from some of the treatments that some of our patients take. This is what came across years ago with one particular drug which was causing cardiac arrhythmia problems. Had it not been investigated and the issues recorded, it would never have come to light. I take this matter extremely seriously and thank the Deputy for raising it.
I thank the Minister.
I welcome the Minister's alarm. Only last week, officials from the Minister's Department telephoned my office seeking the report. It is a source of great concern that the consistency with the Minister's alarm, with respect to the officials in the Department, would raise some questions in light of the fact that somebody from the Opposition benches had to be contacted to identify the report to which I have referred. Of the two audits, one was involved in a community mental health service where there are some particularly startling details. Fewer than 25% of the incidents involved in the investigation were notified in accordance with the law and half of the incidents investigated did not provide for a review with respect to the deaths involved. The standard review was performed but, largely, there is no standardised approach within the service. Also there is no evidence to suggest that an operational plan was developed, subsequent to establishing an investigation, around what had been identified in the investigation was provided for within that centre. Will the Minister comment on the fact that we have had 18 recommendations since January? What actions has he taken with respect to the two audits? I would be alarmed if this report only came to his attention last week.
I assure the Deputy there are recommendations and they are being put in place. The HSE mental health division, in conjunction with the Mental Health Commission, should review the completeness of the notification circumstances to ensure that sudden unexplained deaths in persons in receipt of services for more recently developed service problems will be captured, that is, home care and assertive outreach programmes, etc., that the HSE mental health services should ensure that a record of all patients notified of an incident of sudden unexplained death is kept, that the HSE mental health services should ensure that incidents of sudden unexplained deaths of persons in community and mental health services are investigated and that the systems analysis methodology is applied, and the HSE mental health division should ensure that services are fully aware of and compliant with the process involved in documenting the development, monitoring and review of service users' individual care plans, as set out in the Mental Health Commission document on individual care planning in 2012. The full list of recommendations is available and can be forwarded.
It is a fact that there has been a general failure to investigate the contributory factors to the deaths involved. The report clearly indicates that the Department's failure to adhere to the legislation and the regulation has resulted in a collapse in a standardised approach. That only one in eight of the investigations undertaken was consistent with the approach set out by the systems analysis methodology, to which the Minister referred, is unacceptable. If we are to learn anything from the crisis within the country with respect to death by suicide we need to establish where the systems are breaking down within the HSE and why validation of compliance was not possible in cases due to, for example, the lack of supporting documents, maintaining files and adhering to standing operational procedures.
We are failing the most vulnerable people by failing to ensure we follow regulation procedure in this respect.
I take this matter very seriously. I have pointed out what has been recommended and note the word "should" appears a lot. As far as I am concerned, the word "should" will be replaced with the word "will". These are the most vulnerable people and they cannot speak for themselves. Therefore there is a requirement for us to look out for and speak up for them. I and the Minister of State, Deputy Lynch, will ensure these audits are carried out properly, that investigations are properly supervised and reported and that we get proper information speedily. A range of consequences must be developed for those who do not perform as per their contract and duty.
