Portlaoise mental health centre receives critical risk for seclusion on annual and focused inspections
We have this morning published an annual and focused inspection report for the Department of Psychiatry at the Midland Regional Hospital in Portlaoise, which received a critical risk rating for the use of seclusion following both inspections.
The reasons for the critical rating included the fact that residents had to wear refractory clothing without any indication that this was necessary, and personal searches did not respect the right of the patient to dignity, bodily integrity, and privacy as they were used to remove clothing from residents.
Refractory clothing is anti-ligature clothing placed on a patient where there is serious risk of self-harm. It is rarely used in modern mental health services as patients in seclusion should be observed at all times. The wearing of refractory clothes constitutes a risk to patients’ privacy and dignity. Personal searches, which are provided for under regulations in some circumstances, is the searching of a resident, his or her belongings, and the environment in which he or she is accommodated.
“The refractory clothing worn in seclusion in this centre did not respect the right of the patient to dignity, bodily integrity and privacy, and in this case refractory clothing was worn by patients in 90% of seclusion episodes,” said the Inspector of Mental Health Services, Dr Susan Finnerty. “This is far in excess of what happens in other approved centres where refractory clothing is only used rarely and under strict criteria. In general, restrictive practices, such as personal searches and wearing of refractory clothing, are an affront to the dignity and privacy of residents and should only be undertaken under clearly documented and specified criteria set out in policy, and only after a comprehensive risk assessment. The centre did not adhere to these criteria and the human rights of residents were therefore impacted adversely.”
The Chief Executive of the Mental Health Commission, John Farrelly, noted that there has been little improvement in compliance at the centre over the past five years. “Our regulatory teams have been following up on this matter and we would expect to see significant improvement in policy and practice around the use of seclusion during the next inspection. We would also expect the centre to address the other high-risk ratings and hope see an increase in the centre’s overall compliance.”
The Department of Psychiatry at the Midland Regional Hospital in Portlaoise is the acute psychiatric admission unit for Laois/Offaly Mental Health Services. The centre had forty-two residents at the time of inspection and consisted of separate male and female wards.
The centre received an overall compliance rate of 78%. This was an increase of 6% on its performance in 2020. There were four conditions attached to the centre at the time of inspection. The centre was found not to be in breach of three conditions – all with respect to premises - but was found to be in breach of the fourth condition relating to staffing.
The centre was found to have one critical and five high risk non-compliances upon inspection. The centre received the critical risk for the rule on the use of seclusion. The seclusion room on the
female ward did not ensure respect for resident dignity and privacy because the privacy blind on the door of the seclusion room could be opened and closed by any resident or non-clinical staff member who had access to the main corridor on the female ward, where the access door to seclusion was located.
The clinical files - for each of the three episodes of seclusion inspected - documented that the three
residents were requested to wear refractory clothing. The reason residents were not allowed to wear their own clothes was not documented in their individual care plans. In two episodes, the reasons for placing the resident in refractory clothing were not documented in the risk assessment or risk management plan. In two episodes, clothing did not respect the dignity of the residents. One personal search did not respect resident dignity, bodily integrity and privacy. In three episodes of seclusion the written record of the resident made by a nurse every 15 minutes did not include the level of distress and behaviour of the resident.
The centre received high-risk non-compliances in the areas of premises, searches, individual care plans, privacy and staffing. Under the regulation for premises, the inspection noted that there were numerous decorative and maintenance issues including damaged bookcases in the sitting room, worn and damaged floor coverings, damaged leatherette chairs, stained ceiling tiles and marked and discoloured paintwork. Privacy screens were damaged and there was a cracked window in a bedroom. The garden area was bare, there was little furniture and no recreational facilities for residents in the garden. There was also no programme of decorative maintenance.
In response to the critical risk found in relation to the rules governing the use of seclusion during this inspection, the MHC issued an immediate action notice which required the HSE to take immediate steps to urgently assess risk to residents and put measures in place to ensure that residents were appropriately supervised and safe while requiring the use of seclusion.
The MHC also took the unusual step of conducting a focused inspection. This took place on October 18th, 2021, less than two weeks after the annual inspection. The focus of this inspection was assessing compliance with the rules governing the use of seclusion. The centre again received a critical non-compliance on foot of this additional inspection.
The reasons for this finding included that fact that residents had to wear refractory clothing while in seclusion in 56 out of 62 (90%) of seclusion episodes since 1 January 2021. The files of six residents who had been in refractory clothing while in seclusion were examined. In the six files inspected, the use of refractory clothing was not documented in the residents’ individual care plans as required by the rules. In the clinical files inspected, there was no indication in the risk assessment that refractory clothing was necessary for the resident, nor was the use of refractory clothing part of their risk management plan as required by the rules.
Each of the six residents was searched prior to seclusion. The search was used to remove residents’ clothing as well as any hazardous possessions. There were no reasons in the individual care plans, clinical files or risk assessments and management plans to justify these searches, and this therefore constituted an affront to residents’ dignity, bodily integrity and privacy.
MHC has had substantive engagement with the service since the inspections, including a recent regulatory compliance meeting in January 2022. In addition to the immediate actions required, the service has now provided evidence of remedial actions and satisfactory plans to address the critical non-compliance. The HSE has provided evidence that these practices have now ceased and that safeguards are in place to protect residents’ privacy and dignity. MHC continues to monitor these remedial actions closely.
You can read our full statement here.
The Department of Psychiatry at the Midland Regional Hospital in Portlaoise Inspection Report 2021
