Eating disorder clinic did not 'formally document' resident's attempt at self-harm

Inspectors also found that an appropriately qualified staff member was not on duty at all times, "thus compromising the safety of residents". File photo

An independent therapeutic service failed to "formally and adequately document" a resident's attempt at self-harm, an inspector for the Mental Health Commission (MHC) found.

The Lois Bridges Unit in Dublin, which specialises in the treatment of eating disorders, recorded only three incidents in its log since the last inspection, but it was found that a "significant event involving attempted self-harm" was not formally reported.

The management team at the unit said the incident was reviewed by them, but evidence of this review was not provided to the MHC inspection team.

The centre achieved 85% compliance on the most recent inspection, a decrease of 14% on the previous year.

“Caring for patients with an eating disorder is a very specialised service and it is disappointing that this centre had a number of serious concerns on this inspection,” said the Inspector of Mental Health Services, Dr Susan Finnerty.

“The fact that staff at this centre did not formally and adequately document as an incident a serious event involving attempted self-harm is worrying."

The inspection team also found that the centre contravened its own exclusion criteria for admissions on four separate occasions.

The policy states that residents diagnosed with Bulimia Nervo must be seen by a gastroenterologist prior to admission, but there are three instances where there was no indication that this policy was followed.

The centre also received a critical risk rating as the skill set of the nursing staff was found to be insufficient to meet residents' needs.

Inspectors also found that an appropriately qualified staff member was not on duty at all times, "thus compromising the safety of residents".

The MHC escalated the matter, requiring the service provider to give assurances that these critical risks were being addressed, which management at the Lois Bridges Unit provided.

Merlin Park University Hospital

In Galway, the Wood View Unit at Merlin Park University Hospital achieved a 97% compliance upon inspection, a 26% increase on its 2020 inspection.

The centre was found to be high risk non-compliant with associated regulation for several reasons, including several offensive odours, unguarded radiators which were "excessively hot" and environmental maintenance not carried out with due regard to patient, resident, staff or visitor safety and well-being.

The Child & Adolescent Mental Health in-patient unit in the same campus also achieved a 97% compliance, the same score it achieved in its 2020 inspection.

The inspection found that the centre was high-risk non-compliant when it came to the rules governing the use of seclusion.

It was found that residents in seclusion did not have suitable access to toilet and washing facilities, while the floor in the seclusion room was not padded and was made of a hard-fitting material which was not conducive to resident safety.

The Chief Executive of the MHC, John Farrelly, said he was disappointed to note the poor results around premises, facilities, and access to basic amenities in two of the centres.

“It was very clear from the reports that certain parts of two centres were nowhere close to the standard that we would deem acceptable,” he said.

“Weaknesses such as offensive odours, excessively hot radiators, and residents in seclusion not having suitable access to toilet and washing facilities is simply not good enough and will never go unchecked or without comment under our watch.”