Mental Health Commission: findings of HSE report represent a catastrophic failure of oversight, supervision and accountability

The Board of the Mental Health Commission has this afternoon written to the Minister for Mental Health, Mary Butler TD, stating that the circumstances outlined in the HSE’s report on the look-back review into Child & Adolescent Mental Health Services (CAMHS) in South Kerry represent a catastrophic failure of oversight, supervision and accountability underpinned by failings of governance at local, regional and national level.

The letter has been written by the Board to the Minister pursuant to Section 33(3)(d) of the Mental Health Acts 2001-2018, which provides for the MHC to ‘furnish, whenever it so thinks fit or is so requested by the Minister, advice to the Minister in relation to any matter connected with the functions or activities of the Commission’ and it follows a comprehensive review of the HSE report by the MHC Executive and Board in recent days.

The letter said that although the onus for change and improvement lies with those managing and working in services, independent oversight of the report from here forward is both appropriate and necessary to ensure that all the recommendations are fully and effectively implemented. As the MHC’s regulatory function only relates to approved inpatient mental health centres and does not extend to community mental health services, the MHC told the Minister that it believes that what has transpired in the Cork Kerry Community Mental Health Services, regarding the CAMHS service, strongly supports the recommendation that the MHC be given full regulatory powers over all areas of mental health services in Ireland to include those relating to community mental health services.

The letter also informed the Minister that the Inspector of Mental Health Services, Dr Susan Finnerty, will be conducting an independent review of the provision of CAMHS in accordance with her powers under the 2001 Act. Dr Finnerty had scheduled to do this review prior to publication of the HSE report in order to assess whether there had been improvements in CAMHS provision since a similar review in 2017. The scope of the Inspector’s review will include the number and resourcing of teams, training and expertise, facilities, governance structures and processes, good practice initiatives, young people and their families’ involvement, and any other matters deemed relevant. The MHC will publish the Inspector’s report and its recommendations.

The MHC has formally advised the Minister that a number of actions be undertaken as a matter of urgency. These consist of ensuring that the HSE transparently and fully implement all the recommendations emerging from the look back review and that this process be supervised by a panel of independent experts who have relevant qualifications and experience; that the national audit of all 72 CAMHS teams should have its terms of reference and scope agreed and overseen by independent experts; and that the HSE immediately review and update the CAMHS Standard Operating Procedure 2015 and the CAMHS Operational Guideline 2019, both of which, in the view of the MHC, are not underpinned by current best practice.



“This level of harm must be the catalyst for change,” said the Chief Executive of the Mental Health Commission, John Farrelly. “This change will require clear, planned and decisive measures to be taken to reform our mental health service. The Mental Health Commission and other key stakeholders - including service users and their families - have known that comprehensive regulatory reform of all our services has been a critical requisite for a long, long time. Sadly, it is only when a catastrophic failure like the situation that was permitted to occur in South Kerry comes to light that the wider public realise that this change is now urgently required.

“The time for reform of Ireland’s mental health services is now and it should begin with the reinstatement of a National Director for Mental Health in the HSE. This is something which the MHC has advocated for since the removal of this critical position in 2017 and which was referenced by the Minister in the Dáil last week.”

The Chairman of the Mental Health Commission, John Saunders, said that the MHC acknowledged at their Board meeting today (Monday) the grave extent to which children and their families have suffered as a result of the failures documented in the report.

“The primary concern of the MHC now is that no further harm is caused, and this is why we have formally written to the Minister and furnished her with our advice and recommendations,” he said. “We have made clear in the letter that the MHC is willing to meet the Minister and her officials to discuss any issues arising from same. In addition, we have also told her that we would like to meet with her once the Inspector has completed her review and it has been published.”

You can read our full statement here.