‘Change how patient deaths are probed’

HSE report points to 13 fatalities

A HSE report has called for changes in how patient death investigations are carried out.

The report into Carlow, Kilkenny, and South Tipperary mental health services, yet to be published, also calls for changes in existing governance structures.

It wants immediate attention to be given to a cluster of 13 fatalities among patients and service users following concerns by consultant psychiatrists.

A group of local consultants wrote to junior health minister Kathleen Lynch last month expressing concern about the safety of local clinical governance arrangements. They wrote that they felt devalued and ignored and did not believe the HSE was appropriately addressing their concerns.

Since the end of 2012, the psychiatrists have refused to take part in HSE clinical governance meetings as they believe the system “isn’t safe”.

On RTÉ radio yesterday, one of the co-authors of the report, Colm Henry, said particular concern was raised over an investigation into patient deaths and serious incidents. However, he called for the consultants to re-engage with clinical governance structures immediately.

The report describes the disengagement from local management groups by the nine doctors as “dangerous and unacceptable risk” to the mental health services.

The report is written by Dr Henry, the HSE national clinical lead, and Cork-based consultant psychiatrist Eamon Moloney.

In a radio interview, Dr Henry confirmed that investigations into the deaths of the 13 patients and services users were currently being re-examined.

“We did make a strong recommendation that all of the cases that led to the consultants’ concerns be reviewed and all of the process of the original investigation reviewed and any learning points fed back to the clinicians concerned,” he said.

His understanding was that some of the individual case reviews were completed and others were nearing completion.

An external implementation of the review’s recommendation is also called for in the document.

Dr Henry also said he and Dr Moloney believed the consultants should fully re-engage with the governance structure. “We have stated very strongly where we think things must improve and must get better and we have, I hope, demonstrated a pathway to how this can take place, to how they can re-engage.”

Nine of the 12 consultant psychiatrists withdrew from governance structures in November 2012. They have continued treating patients and carrying out clinical duties.

Fianna Fáil spokesman on mental health and disabilities Colm Keaveney said the report reinforces the concerns of the consultants.

He said it was obvious the system was not fit for purpose — the matter had been raised with Ms Lynch, who had not acted in any meaningful way. He called on Ms Lynch to intervene immediately and investigate why the consultants’ concerns remain largely ignored.

“If the clinical leaders of the system have no faith in it, then what hope is there for the service users,” said Mr Keaveney.