As Kay Barrett stood at the rear of the courtroom, agitated and upset, her solicitor spelled out for the judge just what had transpired.
"Kay is hearing voices in her head, she feels threatened," Jack Purcell told Judge James McNulty in Clonakilty court last February.
"Last week she thought the house was on fire. She says she would prefer to go into prison for a period of time. It seems the lesser of two evils."
It turns out it may well be, but mostly through a lack of other options. Kay Barrett of Donoghmore in Co Cork is currently in Limerick Prison, not due for release until early November this year.
It follows the triggering of suspended sentences for convictions which had accumulated due to the repeated breaches of a safety order, initially put in place to act as a deterrent, her family believing that the other option — a significant mental health intervention — was not open to her.
That court appearance in February was unscheduled and came about due to alleged breaches of her bail. Kay looked hot and flustered. At one point she stood almost doubled over, her forehead in the palm of her hand.
The court was told of the suspended sentences hanging over her. It was admitted she had made a number of 999 emergency calls on one day and more again that very morning. It was a condition of her bail that she refrain from making those calls unless there was an actual need. A previous court hearing last December had heard that she had made 200 such emergency calls in the space of a month.
She had produced a knife when gardaí called to her home. And now, here she was, clearly in the grip of something she was trying but failing to control. "I am physically sick as well as mentally sick," she told the court.
Mr Purcell said she had been taken to the Mercy Hospital over the previous weekend and the judge said she could hardly be faulted if she did need assistance and needed attention. Sgt Paul Kelly said it was alleged that on one of the recent 999 calls, Kay had alleged she had a firearm and had threatened self-harm. Gardai had had to remain at the scene for a number of hours and an ambulance was also called.
On that day in Clonakilty last February, Judge McNulty remarked: "Kay Barrett is clearly in turmoil and her mental state is clearly deteriorating." Bail was revoked. Kay was remanded in custody for sentencing, which subsequently took place, facilitating her current stay in prison. Mr Purcell had consented to a longer remand "to help her to get settled in".
"I think you have called it right," Judge McNulty had said. "It is the lesser of two evils."
It wasn't always like this. Kay's sister, Clair, describes her as "a lovely person", someone who was popular and who was leading her own life. She recalls how Kay, now 42, lived in London for a time, working as a nanny; someone who had a boyfriend and was planning for the future.
Clair clearly cares deeply for her sister, as do the other members of the family, including their aunt, Carmel, and father, John. They have seen the issues, from 2009, when Kay had a breakdown, to 2017 when, having returned to Ireland, she had another setback. But there was a history.
Clair explains that their mother had a diagnosis of schizophrenia and spent much of her adult life in residential hospital settings, including the Carraig Mór Centre, which is a Psychiatric Intensive Care Unit in Shanakiel on the outskirts of Cork city.
Kay was initially diagnosed with schizophrenia, but then it changed to emotional deregulation. Another expert said she was bipolar. According to Clair, Kay is "somewhere between the three" — and now stuck between the criminal justice and mental health systems.
"It's not a sympathy thing but it's just the fact that mum was in the system and we visited her every week and we thought she had a horrible life and now we see that she had a better life than Kay," Clair says. "Because Mum had mental health issues, Kay's early months were not very stable.
"Kay has had attachment issues her whole life.
"Mum was diagnosed with schizophrenia and Kay has the same thing but the diagnosis has changed. It's clear that there is a link.
"I've said that to the doctors and they say 'oh, it's a moveable feast'. She is also emotionally deregulated, but she's also been diagnosed with bipolar so how can it be that our mother can be in Carraig Mór for all those years, and Kay is just unfortunately gone down this other way and is locked out of the mental health system completely?"
Another person familiar with the case but who does not wish to be named believes that a switch in diagnosis away from schizophrenia worked to Kay's disadvantage. Her repeated calling of the emergency services was, in their view, driven by a mental health issue. Clair says it is a "coping mechanism". Everyone agrees that it places a huge strain on already overworked gardaí and medical personnel.
And so, some time ago and, according to Clair, at the "well-intentioned" suggestion of the gardaí, the family sought the court order that would put margins on Kay's behaviour, so as to protect her loved ones and temper her behaviour. It didn't work.
The person familiar with the case said the repeated breaches brought Kay before the courts, but both Judge McNulty and Judge Colm Roberts sought to avoid sending her to prison. Ultimately, she ran out of chances to avoid incarceration.
According to Clair: "Judge McNulty, I feel for him, because I know that he has compassion and I have seen him communicating with Kay in such a lovely way but his hands are tied and he knows that this is not the solution but there is nowhere for him to go."
Regarding the original order, she says the gardaí were hugely frustrated with the situation, and there was a view that maybe engaging with the court could open up mental health supports. As for the family, "we were desperate," Clair says. "We didn't know what to do, we never thought that it would lead to her to be in prison for 12 months potentially..."
In a letter to the court in early 2021 and shared with the, Kay's aunt, Carmel, referred to her initial imprisonment and how, in her view, mental health services had failed Kay.
"Kay has a lot of abandonment/emotional issues as her mother was institutionalised long-term in Our Lady’s Psychiatric Hospital and when she becomes emotionally unstable and panicky, she turns to the Gardaí as they have to respond," she said.
"We are now seeing Kay’s personal efforts throughout her life to deal with her issues, (even training to become a counsellor and working many years as a nanny) being totally undermined by state services.
"This imprisonment comes as a climax to a series of disconcerting decisions made by the health authorities over the years since Kay had a first nervous breakdown nine years ago at the age of 31 and was diagnosed as being bipolar.
"Since 2017 Kay’s diagnosis, medication and therapy have frequently changed or been disrupted. In the first years after diagnosis, she had the occasional short stay in mental health centres, and was mostly able to live a normal life though on constant medication with little rehabilitation. However, over time an increasing anxiety and anger appeared. Her bipolar diagnosis was replaced by schizoaffective disorder and then to Unstable Borderline Personality Disorder.
"Since May 2019 she has suffered almost bimonthly psychotic angry behavioural episodes, which result in traumatic A&E visits, Gardaí and ambulance service use and numerous 72-hour admissions to St Michael's Psychiatric ward in the Mercy in Cork City. As her medication was patently not effective, the medical opinion put the responsibility on her behaviour, diagnosed her as having solely a Borderline Personality Disorder (BPD) after a previous diagnosis of bipolar, which is generally a lifelong illness.
"At this point the mental health services made a disruptive decision which came as a total shock to Kay and her family: Kay was discharged from all mental health services in October 2020 as she was said to be uncooperative and not using the techniques and skills explained to her to deal with crises. Kay was informed that her diagnosis no longer entitled her to the mental health care and that she had a problem of 'bad behaviour'. When in panic and distraught she has been calling ambulances and the Gardaí to her home in Donoughmore.
"The latter, at a loss, suggested that the only way of getting the mental health services to fulfil its obligations was by getting a safety order against Kay so that on a subsequent Garda call-out she would be referred to a judge, who would logically refer to mental health care. Kay has been in front of five different court judges in Clonakilty, Bandon, Bantry and Macroom and all are in agreement that this is clearly a medical matter and Kay is not a criminal, her anger outbursts are due to lack of care.
"When we (Kay’s sister and father) took out a Safety Order on Kay we thought we were acting in her best interests, never thinking our action would result in Kay being in prison. It is morally wrong and we are extremely upset at this outcome."
One potential solution is Dialectical Behaviour Therapy (DBT), but according to Clair, when it was suggested that Kay undergo the intensive programme, she was told it would be a two-year wait.
"It was saying hang on, hang on for two more years and she became more and more frustrated with the system and she was in and out of the Emergency Department and I feel if she was in the DBT programme, an intense 12-week programme, it might have saved her."
In February of this year, DBT was again floated as a possible solution during the court hearing. But any regular attendee at district courts will know that directing access to mental health facilities, all the way up to the Central Mental Hospital in Dundrum, is a road full of roadblocks and potholes. The typical answer is that there are no beds available, and the person will have to wait.
A spokesperson for the Irish Prison Service said there is no up-to-date data on the levels of prevalence of mental illness within the prison population, with information on the level of mental health conditions derived from studies done in 2003 and 2005.
"For all mental illnesses combined, rates ranged from 16% of male committals to 27% of sentenced men, while in women committed to prison the rate was 41%, with 60% of sentenced women having a mental illness," the spokesperson said. "For the more severe mental illnesses, rates of psychosis were 3.9% amongst men committed to prison, 7.6% amongst men on remand and 2.7% amongst sentenced men. Women prisoners had psychosis in 5.4% [of cases]."
The Irish Penal Reform Trust is familiar with Kay's case and executive director Saoirse Brady said mental health was a serious issue among the prison population.
"There is significant unmet mental health need in prison," she said. "People with severe mental health issues who have been assessed as needing hospital treatment, for whom prison is not appropriate, are often left on waiting lists of over a year to access treatment.
"When we talk about people who are experiencing acute mental health issues, we are talking about the sharp end of mental health need for people in prison, but there is usually between 300 and 400 prisoners engaging with National Forensic Mental Health Services and Irish Prison Service data has shown that up to one-third of people in prison can be on waiting lists to access in-prison psychology services at any given time. The wide-ranging level of need is substantial.
"What we have now is a damning situation where the State is allowing the prison system to be used to fill gaps in mental health services. While we recognise that there is political will for this to change, action to date has been slow."
A spokesperson for the Department of Justice said that a High-Level Task Force (HLTF), established in April 2021 by the Justice Minister in conjunction with the Health Minister to consider the mental health and addiction issues of persons in prison and primary care support on release, has held 10 plenary meetings to date and has established three subgroups on diversion, capacity issues in the Prison Service and National Forensic Mental Health Services, and community issues, including care after release.
"Each of the subgroups comprises of relevant experts, chaired by high ranking officials from the criminal justice sector, with the health leads represented and contributing to all," the departmental spokesperson said. "Each of these groups have met on at least 12 occasions. The HLTF has engaged with a large number of relevant bodies and civil society actors, including meeting with the Mental Health Commission on December 2 and with the Chairperson of the National Prison Visiting Committees Chairpersons Group and the Inspector of Prisons.
"The work of the Taskforce is continuing apace. The aim is to finalise a report, including a high-level implementation plan assigning responsibility and timelines for its recommendations shortly, after which it will be submitted to Government for approval. [Justice] Minister [Helen] McEntee met with [Health] Minister [Stephen] Donnelly as well as other relevant Ministers and the Chair of the Taskforce on July 21 and officials from both Departments have been engaging in further discussions in order to progress matters. Publication of the report is a high priority for the Minister and she hopes to be in a position to do so, in conjunction with her colleague the Minister for Health, in the autumn."
Saoirse Brady said the work of the HLTF is to be welcomed and that the independent Prison Health Needs Assessment, which aims to determine future health service requirements in prison, should be published as a matter of urgency.
"Each day that goes by without action means another day where people’s mental healthcare needs are not being adequately met," she said.
"This can prevent causing further trauma and may even save lives. However, this will require a fundamental shift in our approach to mental health at all points of contact with the criminal justice system.
"Failure to provide appropriate care and accommodation in the community for people with mental health issues cannot be resolved by the Department of Justice alone. We need a strong multi-agency focus on keeping people out of prison and this focus on diversion must be underscored in the report of the High Level Task Force on Mental Health and Addiction. We know there is an appetite for this type of diversion. For example, while data we have is quite dated, previous public opinion polling suggests that the vast majority of the Irish public believe that mentally ill offenders should be treated in a mental health facility instead of being sent to prison.
"We need a robust domestic inspection regime that is adequately resourced to routinely inspect prisons at regular intervals and investigate the conditions for everyone in prison including the significant portion of people with severe mental health needs. International human rights bodies, Prison Chaplains, and Prison Visiting Committees have all outlined the severity of the mental health crisis in Irish prisons. The forthcoming Inspection of Places of Detention Bill offers an opportunity to strengthen and resource the Inspectorate to highlight these serious issues of concern."
The HSE said it could not discuss individual cases.
"I feel like her choice is being taken away from it," Clair says. The family have been "very stressed" by what has happened to Kay, she continues.
Kay's behaviour, from saying she would throw herself into the river or that she would burn the house down, the production of knives — they were "a cry for help", and yet they acknowledge that something must be done to ensure Kay doesn't harm herself or others.
"We were saying [recently] was it better for her to be safe in prison rather than shouting and roaring on the streets? I don't know if I am doing more harm than good, bringing it all up..."
Kay does not have a problem with drink or drugs. For both Clair and Carmel, she is not a criminal, yet she finds herself in Limerick Prison. Despite her difficulties, she is aware of where she is and what has occurred — "when she is lucid, it's heartbreaking", Clair says. But what is the alternative? She believes a residential centre that could address her needs, even just at times of mania, would help. But is it any closer to becoming a reality? What happens when Kay comes out of prison later this year? What happens if she resumes making the calls?
They would have liked Kay to contribute directly to this article, but they also had to consider how it might impact her. They want to help her, and for Kay to have her own voice.
"Carraig Mór is still there and I don't know why Kay can't be a part of that, like Mam.
"What is Kay's future?" Clair asks. "What is her future? If she continues ringing the guards for her coping mechanism, is she just going to spend the rest of her life in jail, for a crime that is crying out for help?
"I understand she can't keep wasting police time but something has to be put in place for that not to happen."