Mental Health Commission’s Annual Report 2018

On 20 June 2018, The Mental Health Commission (“MHC”) published its 2018 Annual Report (the “Report”). The Chief Executive of the Mental Health Commission,

John Farrelly, warns in the Report about significant governance and management deficits within Irish mental health services. He has said that it is difficult to see how some of the country’s in-patient mental health units could be registered in the future without significant improvements in levels of compliance.

Mr John Saunders, Chairman of the MHC notes that while some parts of Ireland and some service providers are getting things right, there is further work to do in order to ensure that all persons have access to appropriate mental health care in all parts of Ireland. Mr Saunders also recognises important developments that occurred in 2018 to include the first steps in the development of the MHC’s new strategic plan ‘to regulate and engage to promote, support and uphold the rights, health and well-being of all people who access mental health and decision support services’ and the creation of a clear pathway for the establishment of Ireland’s Decision Support Service (DSS). However, he also highlights that the level of change in our mental health service provision is uncoordinated, ad hoc and slow.

He emphasises that there are three key challenges for the mental health care system in Ireland which are as follows:

1. Governance – To establish a system of governance that drives best practice across the whole country.
2. In-patient approved centres - The specialist in-patient approved centres must be up to standard.
3. Treatment and recovery model - The Government needs to continue moving the treatment and recovery model to specialist professional community care.

Non-Compliance The following areas of concern regarding compliance by Approved Centres with the MHC regulations are identified in the Report:

1. Maintaining premises that are clean and fit for purposes. The report found that in 2018 70% of approved centres remained dirty, malodorous and poorly maintained. Non compliance by six approved centres was rated as a critical risk.
2. Inadequate staffing. The Report recognises that there is a national shortage of mental health staff and this was evident in most approved centres.
3. Preparation of an appropriate individual care plan for each resident in an approved centre. The Report highlights that there is concern that there is a lack of resident involvement in their own care planning.
4. The use of seclusion. The report notes that 67% of approved centres did not comply with the Rules Governing the Use of Seclusion. The report notes that seclusion should only be used for the shortest time possible and that lengthy periods of seclusion are counter-therapeutic.
5. Compliance with Part 4 of the Mental Health Act – Part 4 of the Mental Health Act 2001 specifies that the administration of medicine to an adult patient who is detained for longer than three months cannot be continued unless the patient gives consent in writing or the medicine is approved by the treating consultant psychiatrist and authorised by another consultant psychiatrist. There was increased compliance with Part 4 of the Mental Health Act in 2018 to 81 % compliance from 50% in 2016. The reason for non-compliance in four approved centres was due to a failure to assess the capacity of the patient to consent to treatment.
6. The use of physical restraint. The report notes that 81% of centres which used physical restrain were non-compliant. For example, a number of them failed to carry out a physical examination of the resident/patient following the episode of restraint. This is required by the Code of Practice on Physical Restraint due to the risk of injury.

2018 Themed Report – 24-hour supervised residences for people with mental illness

In 2018, the MHC carried out inspections of 54 24 hour supervised residences across a number of Community Healthcare Organisations. The MHC was very concerned with the lack of privacy for residents as they found that 91% of residences shared rooms with no privacy within those shared bedrooms. The MHC found that there are continuing breaches of human rights in 24-hour supervised residences with regard to the right of privacy, the right to a clean, well-maintained accommodation, the right of services users to choose where they would like to live, the right to independent living with appropriate supports and the right to access appropriate care and treatment through access to rehabilitation and recovery services.

Child admissions to adult units

The Report notes that there were 84 child admissions to 18 adult units in 2018. This was an increase from 2017 where there were 81 admissions.  The reason for the majority of admissions to adult units is due to an immediate risk to the young person or others, or due to the lack of a bed in a specialist CAMHS unit.

Enforcement Actions

The MHC took 44 enforcement actions relating to 23 approved centres in 2018 which was an increase on 2017 during which 23 enforcement actions occurred. The report notes that the increase was due to the increased collection of high-quality compliance data across a number of years leading to enforcement based on trends of ongoing non-compliance. The majority of enforcement actions (73%) arose out of annual regulatory inspections. Other enforcement actions arose out of quality and safety notifications, compliance monitoring and focused inspections.

Decision Support Service (“DSS”)

During 2018, extensive work was undertaken in preparation for a fully operational Decision Support Service. This included organisational design, scoping the service, project governance, scoping ICT infrastructure, defining the regulatory framework, undertaking stakeholder engagement and mapping out customer journeys. The Decision Support Service is provided for under the Assisted Decision Making (Capacity) Act 2015 (‘2015 Act’). The 2015 Act establishes a statutory time specific and issue-specific assessment of capacity and sets out important guiding principles, emphasising privacy, autonomy, and minimal intervention. The supports provided for and monitored by the Decision Support Service will help to ensure that people are afforded the fundamental human rights to make their own decisions as far as possible about their personal welfare and their property and affairs.

Legislative Developments

The 2015 Act is largely not yet commenced. However, certain sections have been commenced, which include the appointment of the Director to allow for the establishment of the Decision Support Service. The Director was appointed in October 2017 and has a number of specific functions and responsibilities set out under Part 9 of the 2015, including providing information and promoting public awareness.

The full publication of the Mental Health Commission’s Annual Report 2018 can be accessed here.