Central Mental Hospital: 'We tolerate a system that no other country would'

It is the largest single mental health project in the country. However, in a few years of opening, the new Central Mental Hospital will be full due to the pent-up demand for forensic psychiatric services, reports Security Correspondent Cormac O’Keeffe.
Central Mental Hospital: 'We tolerate a system that no other country would'

The Central Mental Hospital in Dundrum, Co Dublin. The building was originally constructed in 1850. Also known as the National Forensic Mental Health Service (NFMHS), it provides secure beds at high, medium, and pre-discharge levels. Picture: Frank Miller

It is sobering to think that the brand new, and long-awaited, national psychiatric hospital will be full within a few years, such is the demand.

The new Central Mental Hospital, located in Portrane, in north Co Dublin, will increase the number of beds by two-thirds, from 102 to 170.

In anyone’s books that seems like a substantial increase.

However, because it is coming from a low base and because the beds are being taken up by a constant stream of people being sent by the courts as a result of being found not guilty by reason of insanity (NGRI) its increased capacity will be soon swallowed up.

Over recent years, the ability of the existing Central Mental Hospital (CMH) to take offenders from the prison system — of convicts who have been assessed as having serious psychiatric disorders — has fallen significantly.

CMH

The CMH is the country’s sole forensic mental health facility and is located in Dundrum, South Dublin, in a building originally constructed in 1850.

Also known as the National Forensic Mental Health Service (NFMHS), it provides secure beds at high, medium, and pre-discharge levels.

The recently published HSE Mental Health Service report Delivering Specialist Mental Health Services 2019 says the CMH is an “Approved Centre” with special status under the Mental Health Act 2001 and the only designated centre under the Criminal Law (Insanity) Act 2006.

It also provides forensic rehabilitation and recovery teams that meet the requirements of Section 13A of the Criminal Law (Insanity) Act 2010 concerning the supervision of patients found not guilty by reason of insanity, who are conditionally discharged.

The HSE report said that in 2019, the hospital opened 10 additional beds, increasing inpatient beds from 92 to 102.

The NFMHS also provides in-reach clinics at Cloverhill, Mountjoy, Dochas Centre, Wheatfield, the Midlands, Portlaoise, Arbour Hill, and Castlerea prisons.

This includes a psychiatric in-reach and court liaison service in Cloverhill, the largest remand prison, for diversion from the criminal justice system where possible.

HSE mental health services in Cork and Limerick provide similar clinics in Cork and Limerick prisons.

The NFMHS also provides a highly specialised in-reach forensic child and adolescent mental health service to Oberstown Children Detention Centre, led by a consultant in forensic child and adolescent psychiatry.

The CMH caters for persons who require treatment in conditions of special therapeutic safety and security.

“Typically, patients present a risk of serious harm to others,” said the HSE report. “Seriousness is clinically assessed by Consultant Forensic Psychiatrists according to history of serious violence [homicide or potentially fatal assaults], complex needs [dual and triple diagnosis relevant to violence], institutional behaviour, and other criteria.”

Specialist treatment involves therapeutic programmes “to reduce risk and to reduce the seriousness of risk”.

The report said “highly specialised services are provided in the high-risk environments of prisons and also in supervising those found not guilty by reason of insanity who have been conditionally discharged to the community”.

The NFMHS is the place for referrals from primary care teams in prisons and criminal justice agencies, from community mental health teams and from other agencies including An Garda Síochána, the Courts, and from psychiatrists working in the disabilities services.

“Typically, those referred have a severe, enduring, and disabling mental illness or mental disorder and are thought to represent a risk of harm to others,” said the report.

PRESSURES

Harry Kennedy, director of the Central Mental Hospital.  	Picture: Julien Behal/PA
Harry Kennedy, director of the Central Mental Hospital. Picture: Julien Behal/PA

The CMH has been increasingly experiencing pressure on its capacity, particularly over the last 10 years or so.

On the one hand, it is getting more NGRI cases from the courts and, on average, each of those is staying many years, while, on the other hand, the demand from the prison system has continued.

“If you looked at the system, say 10-15 years ago, the CMH was getting maybe two of those [NGRI] type of cases a year, now it’s getting more than 10,” said Professor Harry Kennedy, executive clinical director of the Central Mental Hospital and head of the National Forensic Mental Health Service.

“They come in — usually they have done something very serious, maybe killed someone, and they stay quite a long time, on average around seven years.

“They therefore accumulate in beds and therefore there are fewer beds available for short admissions.”

Prof Kennedy said: 

“If you go back to when the CMH was admitting 70 people a year, even 100, the vast majority were coming in for a couple of months and going back — but those aren’t happening anymore.”

On a side issue, he explained that people have to plead NGRI — the judge cannot decide if the person is so mentally ill they need to go to the CMH. The latter power is available to judges in Britain but most European countries are similar to Ireland.

The HSE report supports the analysis on the impact of NGRIs on the CMH.

It said: “The number of persons found not guilty by reason of insanity has increased year on year since the law reforms of 2006 and 2010. The obligation on the Mental Health (Criminal Law) Review Board, and on clinicians to act in the best interests of the patient and in the public interest, means that length of stay is no longer falling.”

Statistics in the report on admissions into, and discharges from, the CMH starkly illustrate the pressures:

  • In the period 2009 to 2014, between 52 and 74 people were admitted into the CMH each year — but in the years 2016 to 2019 this number has decreased to between 23 and 30 each year;
  • In the period 2009 to 2014, between 52 and 76 people were discharged each year — but in the years 2016 to 2019 this has collapsed, to between 18 and 21 each year.

Prof Kennedy said: “Our ability to admit people in numbers per annum has reduced since 2010, due to the increased numbers found NGRI.”

The HSE report shows that 68 NGRI cases have been sent to the CMH since 2008. This has impacted on the typical length of stays for the average patient — doubling from 2.1 years in 2008 to 4.4 years in 2019.

Back in 2010, the CMH had 31 patients staying longer than 60 months; that has increased to 46 patients in 2019.

PRISONS

Caron McCaffrey, new head of the Irish Prison Service: ‘Prison is not therapeutically the best place for those who are mentally ill.’
Caron McCaffrey, new head of the Irish Prison Service: ‘Prison is not therapeutically the best place for those who are mentally ill.’

Part of the pressure on the CMH, and the biggest victim, has been the prison system.

As shown in the figures above, total numbers being admitted has drastically reduced in the last six years or so, although there is no specific breakdown for prisoners.

While the total number of people being sent to prison has fallen dramatically, the number of prisoners being assessed for psychiatric disorders is down only marginally.

As mentioned, the CMH runs clinics in most of the prisons, the biggest in Cloverhill Remand Prison, where people are charged and awaiting trial.

Figures in the HSE report show that between 2016 and 2019:

  • Prison committals fell from 15,099 to 8,939 (down 41%);
  • New referrals to the CMH in-reach service fell slightly, from 920 to 887 (down 4%);
  • The proportion of committals being assessed by the in-reach teams increased from 6% in 2016 to 10% in 2019;
  • Total patient reviews (involving new and existing cases) increased during the same period, from 4,375 to 5,673 (up 30%).

The report shows that the largest number of cases are in Cloverhill (315 new referrals and 1,415 reviews), with significant numbers in prisons holding convicted inmates, including Mountjoy (69 new referrals and 1,072 reviews) and Midlands (107 new referrals and 677 reviews).

Based on its size, Dochas women’s prison has a high number of cases (129 new referrals and 704 reviews).

In January 2019, the director general of the Irish Prison Service (IPS), Caron McCaffrey told the Oireachtas Justice Committee that at any one time they had between 20-30 prisoners on a waiting list to get into the CMH.

She said the caseload of the NFMHS in the prisons was around 250 inmates.

“So, there are 250 prisoners who are deemed to have a severe and enduring mental illness, and that would generally be either psychosis or schizophrenia,” Ms McCaffrey told the committee.

She said prison was not the best place therapeutically for these people, despite what she said was the excellent work of the in-reach teams.

An experienced source told the Irish Examiner that it was good the in-reach teams were seeing proportionally more people in prisons.

They said: “The need is clearly there and its good more prisoners are getting help, but those with a serious disorder need to be transferred into the CMH.

“They are on a waiting list and some of the prisoners are at the end of short sentences and won’t be transferred. They will go back out into the community and go round and round in circles. They are often homeless, and are often arrested for small things but the worry is some might do serious things.”

When asked about this matter, Prof Kennedy said: “The biggest problem is there are extremely mentally ill people in prison waiting when there’s almost no chance of getting admitted [to the CMH] before the end of their short sentences — that’s the real problem.”

He said: “Cloverhill remand prison is the trolley system for psychiatry, but it does not generate the outrage that people on trolleys in A&E does.”

He said that while many people in Cloverhill were homeless, sometimes coming from vulnerable and deprived backgrounds, a substantial proportion were university graduates.

“You have young men with schizophrenia, young adults with autism with no access to services — they are in prison,” Prof Kennedy said.

He said that in-reach teams do what they can and that psychologists and social workers are part of the service. “But, at the end of the day, prison is a toxic place,” he said.

“Prisons are prisons, they are not a hospital. You can’t expect to do cognitive behaviour therapy when they share cells and have to go back to a cell mate who will bully the tablets from them or beat them and they have limited means of talking to family.”

WAITING GAME

All of which has led to a mounting waiting list for the CMH with those lucky enough to get on it spending longer and longer waiting.

A spokesman for the Irish Prison Service said it did not manage the waiting list for admissions to the CMH and that queries should be directed to the Department of Health and the HSE.

“The prison service does not have authority to place any patients on the waiting list and only are circulated by the HSE,” said the IPS spokesman.

He said they had access to a “limited number” of beds in the CMH for prisoners “suffering from a severe mental illness who require residential mental health treatment”.

The spokesman said: “There is currently an average of 20 to 30 persons in custody [clinically assessed as requiring admission to the CMH by NFMHS Consultant Forensic Psychiatrists] each week awaiting transfer to the CMH.

“Over the last nine years, the number of prisoners on the waiting list has generally fluctuated between 5 and 33 prisoners.

“It should be noted that all prisoners placed by NFMHS consultants on the waiting list have been clinically assessed as warranting admission to the CMH, which is a tertiary care facility.”

The Department of Health referred queries about the waiting list to the HSE.

The HSE said figures on the actual number of people on the waiting list and comparable figures for previous years were not readily available.

In a statement, the HSE said: “Admissions to the CMH come from the Courts, the Irish Prison Service, and other inpatient mental health facilities nationally; consequently, the waiting list changes daily.

“The team reviews the list on a weekly basis. Due to a high demand for the limited number forensic inpatient beds, admissions are systematically triaged according to the level of therapeutic security required and the urgency of that need.”

Commenting on the waiting list, Prof Kennedy said: “The numbers admitted and discharged each year are falling while demand from the prison population and local approved centres is increasing.

“There has been a large increase in the number of patients found Not Guilty for Reason of Insanity [NGRI]. The waiting list for admission to the Central Mental Hospital is therefore an increasingly prolonged one.”

He said that for “legacy reasons” the NFMHS has two secure forensic beds per 100,000 population, while most modern European states have in excess of 10 secure forensic beds per 100,000 — five times as many.

“Ireland also has fewer acute general adult psychiatric beds in the public service than other comparable countries,” he said.

“It is remarkable that this attracts so little attention or discussion when the adverse effects including criminalisation of the mentally ill are so obvious.”

A study published June last year in the Social Psychiatry & Psychiatric Epidemiology journal found Ireland was third from the bottom out of 16 European countries for forensic beds per head of population.

While Ireland’s was 2.1 per 100,000, countries like Croatia stood at 6.2, Scotland, Finland, and Germany were all at 10, England and Wales stood at 11.7 per 100,000. The countries with the highest number of forensic beds were Belgium (17.5) and Netherlands (23.9).

The HSE report said that following the introduction of ten extra beds in 2019 (bringing it to 102), the capacity of the CMH cannot be increased any more until Portrane comes on stream.

UNCERTAIN FUTURE

Irish Penal Reform Trust executive director Fíona Ní Chinnéide: ‘Cross-departmental co-operation is vital for change to happen.’
Irish Penal Reform Trust executive director Fíona Ní Chinnéide: ‘Cross-departmental co-operation is vital for change to happen.’

The Government has promised a task force to examine the interlinked issues of mental health, addiction, and incarceration.

After taking office, the new justice minister Helen McEntee said: “I also look forward to working with the Department of Health and the HSE on how best to consider the mental health and addiction challenges of those imprisoned.”

The Irish Penal Reform Trust has welcomed the commitment.

However, its executive director Fíona Ní Chinnéide said: “This will require strong cross-departmental co-operation, and must be action-driven and resourced.

“Priorities should include diversion at all points in the criminal justice system, investment in community mental health services, access to appropriate therapeutic settings, and a review of gaps in relevant legislation.”

She said: “It is simply unacceptable that people suffering from severe mental illness are being held in prison for months and sometimes years awaiting transfer to settings where they can receive the therapeutic care they need.

“Prison is a completely inappropriate environment for people in psychiatric distress, and prison officers are neither trained nor should they be required to provide the levels of care needed.”

More immediately will be the opening of the long-awaiting new CMH in Portrane, in north Co Dublin.

The HSE report said the construction of the facility, under contractor Rhatigan OHL, was “continuing apace”.

It said: “The task of relocating to a new hospital is formidable but progressing well. It is expected to be completed and the service to transition in 2020.”

It said the facility will increase the current bed capacity from 102 inpatient beds to 170 (bringing the ratio from 2 per 100,000 to 3.5 per 100,000).

The 170 beds include 10 specialist forensic mental health intellectual and developmental disability (FMHIDD) beds; 10 Forensic Child and Adolescent (FCAMHS) beds (a new addition); a 30 bedded forensic intensive care and rehabilitation unit (FICRU), and additional bed capacity for women which will allow for the development of a care pathway for women.

“The transition programme is being actively developed so that modern, intensive services for the most severely mentally disordered patients will be delivered to international standards of quality and excellence,” the HSE report said.

In a further statement to the Irish Examiner, the HSE said: “The new National Forensic Mental Health facility is currently at an advanced stage of construction and is due to be operational later this year.

“The facility will provide 170 beds in a modern and fit for purpose Hospital in Portrane. This development is the largest single Mental Health Project ever in this country and will provide an exciting opportunity for a range of mental health professionals as part of an increased number of beds and range of services provided.”

There remains some uncertainty as to when exactly Portrane will open, with some expectations that it would finally happen in September, but that may now slip to October at least.

Last November, then minister of state for mental health Jim Daly said the new CMH would be completed “on budget and on time” in the coming weeks.

He said the €170m project had a commissioning timetable of six months and was expected to be operational by the summer of 2020.

In its statements, the HSE press office said: “construction is due to be completed in Q4 2020”.

“Following formal handover from the contractor, there will be a period of three months to complete commissioning, testing, and training before the building can become operational,” it said.

“The facility will open in phases with the main hospital being first to open and followed by the Intensive Care Rehabilitation Unit and Forensic Child and Adolescent Unit.”

It confirmed that the handover date was initially due to be Q4 2019.

Asked about the delay in opening, the HSE said due to the advanced stage of construction the NFMHS Hospital was identified during the Covid-19 emergency as a suitable location to accommodate patients on a temporary basis to assist with the additional capacity demands for the emergency.

“As the buildings were utilised during the response to Covid-19, construction activities were paused,” it said.

“Patients have recently vacated the NFMHS site and the contractor is now working to complete the construction.”

It said: “There has also been some programme slippage from the original Q3 2019 date prior to the Covid-19 pandemic.”

The HSE said it could not reveal the final cost of the build, saying: “As the construction contract is ongoing the final cost is commercially sensitive at this stage.”

Prof Kennedy is looking forward to the new facility and the services, expertise and care it will provide.

However, he said: “New patients found NGRI will overtake the additional capacity within a few years.”

Prof Kennedy said that when you look at the forensic bed figures it means that even when the full 170 beds become operational, Ireland’s ratio of forensic beds increase to around 3.5 per 100,000 people — still a third of the average in modern European states.

He sees forensic psychiatry as an indicator of problems in society and mental health services generally. He said: 

“As a country we tolerate what no one else would tolerate — we currently have one fifth the amount of forensic beds that the British, the Dutch, the Germans, and the Scandinavians have.”

He said that during the Covid-19 crisis Irish authorities were able to house those who were homeless, mentally ill, and living on the streets overnight.

“Prisons have been very quiet in part due to this,” he said. “Will we go back to the same problems?

“In much the same way, standardised mortality rates from schizophrenia and bipolar affective disorder have been worsening in developed countries where they gather the data to measure this — mostly Scandinavia. This is happening at the same time that standardised mortality rates due to cancers and cardiorespiratory illnesses have been getting steadily better over the last 25 years.

“We do not collect such data in Ireland but it is reasonable to think we are in the same situation as other modern European states. Policies such as A Vision For Change and the recent Refresh did not address these problems at all.”

Finishing on the new CMH, he said: “Yes, Portrane will improve things, and we will clap ourselves on the back. But we will need to ensure that we sustain the improvement over the next five to 10 years.”

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