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Within these walls…

The three most recent Reports of the Inspector of Mental Health Services were released late in 2014 and in the first quarter of 2015. They cover a number of mental health facilities throughout Ireland, and are compiled following unannounced inspections.

The most recent tranche, released in April, highlighted issues at the St Michael’s Unit in the Mercy Hospital, Cork, among other facilities. While there was “strong evidence” that staff there worked hard to provide recovery-focused care for residents and therapeutic services and programmes were described as “excellent”, the Inspectors described the medication Kardexes as “most unsatisfactory”.

“There was carelessness evident in the prescriptions,” the report continued, “to the point that one prescription was unsigned and undated. It appeared that nursing staff were unaware of how to fill in the administration documentation.” In their conclusion, the team recommended an audit of medication Kardexes at the facility.

Meanwhile at St Stephen’s Hospital, part of the North Lee/North Cork HSE catchment area, staff struggled with unsuitable premises. While the inspectors were “impressed with the level of care” provided, they stated: “The buildings comprising the approved centre dated from the 1960s and were developed originally for purposes other than the provision of a modern mental health service.”

St Stephen’s Hospital was part of the latest batch of reports and the team continued: “The premises had issues relating to heating, scuffed and scratched paintwork and possible ligature anchor points, although inspectors were informed that a ligature anchor point audit had been carried out since the last inspection.”

One of the earlier inspections, conducted in August 2014, involved St John of God Hospital in Stillorgan, Co Dublin, which comprises eight wards and 183 beds.

While noting that overall, “St John of God Hospital offered good care and treatment to residents in pleasant surroundings… staff were enthusiastic about improving quality of care,” the report raised concerns regarding admission policies.

For a patient who is acutely unwell, distressed and possibly frightened, this causes unnecessary hardship and is not in the best interests of the patient

“Assisted admissions were available for public patients from the Cluain Mhuire Mental Health Services catchment area,” it stated. “However, private patients who required an assisted admission had to be first admitted to the approved centre in their catchment area and then transferred to St John of God Hospital. This meant that the patients had to go through two admission and assessment processes and increased travelling.”

It continued: “For a patient who is acutely unwell, distressed and possibly frightened, this causes unnecessary hardship and is not in the best interests of the patient. There had been a number of complaints about this policy to both the approved centre and the Inspector of Mental Health Services.”

Summarising, the Inspector’s Report described this policy as “unacceptable”, with “the potential to cause unnecessary hardship and distress to patients”.

Prescribing

The report also noted dissatisfaction with what it called “a number of deficits in the prescribing and administration of medication”. It stated that “a number of doctors did not use their Medical Council numbers (MCNs), as required by law. Some prescriptions and signatures were illegible and, in one case, the MCN was illegible”.

However the report stated that overall, “the approved centre provided good care and treatment of residents in well-maintained buildings” and “there was good access to therapeutic services and programmes”.

In 2015, the Inspector’s team visited the Acute Psychiatric Unit at Cavan General Hospital and observed that while the design and fit-out were “not ideal for psychiatric care,” residents had access to a full range of multidisciplinary team members and “there were good initiatives underway to enhance therapeutic provision,” which were supported by the management team.

However, they noted that “the documentation in relation to ECT was maintained in a folder separate to the patient’s clinical file and was located with some difficulty by staff”. It stated: “Inspection of one individual clinical file identified an adverse event in relation to the administration of ECT. A detained patient had consented to a course of ECT treatment. The anaesthetist had failed to administer the required muscle relaxant medication prior to one treatment session.

“There was no record in the approved centre of this event having been entered into the incident log or reviewed by all relevant clinical personnel and the risk manager.”

‘Dignity’

Urgent maintenance and “dignity” issues were raised following the inspection team’s unannounced visit to the Acute Mental Health Unit at Mayo General Hospital in 2014, as well as some “unsatisfactory” aspects regarding prescriptions.

While the team noted that “there was evidence of good care and treatment of residents in the approved centre… all residents had an active individual care plan and there were good therapeutic services and programmes”, the inspectors also called for “urgent input from maintenance” regarding “a number of issues”.

For example, the team observed “a leaking roof, broken toilet, broken laundry and kitchen appliances and plumbing difficulties,” as well as observing that there were no locks on toilet doors. According to the report, it was “possible to look over the toilet doors into the cubicle when someone was in the toilet”.

The centre was also running at 92 per cent occupancy, which was placing “great strain” on the service. It sometimes exceeded capacity, said the report, “resulting in residents sleeping in other approved residences to ‘free-up’ beds”.

While there was a policy in place regarding medications, the team stated that “some of the prescriptions were unsatisfactory. A number of doctors did not use their Medical Council registration numbers, as required by law. Some discontinuation of medication was not signed. One medication had no start date. One medication had not been given to a resident but no reason was documented”.

Outdated buildings

In the 2015 batch of reports, the Inspector referred to a visit made to the National Forensic Service at the Central Mental Hospital. While noting that “the provision of primary healthcare was excellent and all residents had a physical examination within the previous months,” it continued: “The building was outdated and unsuitable as a mental health facility for the 21st Century.

The premises also presented challenged in terms of privacy: “Both seclusion rooms and a bedroom in Unit B had CCTV cameras in operation. The monitors were situated on the corridor outside the rooms. These monitors were clearly visible to residents passing by and by household staff,” noted the Inspector.

“It was agreed by all that the main building of the hospital was no longer suitable as a mental health facility. The building was old, antiquated in places, cramped and poorly maintained. It was expected that a new building would be in place by 2018 and was greatly anticipated by all.”

‘Stigmatising’

Two representatives from the Inspector also made an unannounced visit to the Department of Psychiatry in Roscommon, which serves the Galway, Mayo and Roscommon catchment area, in July of 2014. It was recorded that each individual had a good individual multidisciplinary care plan and that “the approved centre was well managed at the time of inspection and the staff were knowledgeable, focused and caring”.

However, there were issues regarding administration of medicines. “In some cases, regular medication was written in the ‘once only’ section [of the medication prescription sheets on Kardexes], leading to the risk of this medication not being administered,” the report stated. “The prescriptions, in some cases, were untidy and difficult to read.”

However, they also noted that “a new prescription booklet was due to be introduced, which should address some of these issues”.

But the team reserved its strongest comments for the outside area for patients, describing it as “completely inadequate” and “deeply stigmatising”.

The area, which measured approximately 4x4m, also served as a smoking area. While the team recorded that “there are plans to remedy this,” they also said: “The outside area was unfit for purpose, deeply stigmatising and did not respect the dignity of the residents.”

Describing the residents as “cooped-up”, they wrote: “During the inspection, five or six residents were packed into this area. It had all the appearance of a cage.”

Nobody is against the concepts of quality and safety but every initiative requires more manpower and resources

In its conclusions, the report commended staff at the facility for their good management of reconfiguration of services in amalgamating Galway and Roscommon and said the service was coping well with admissions from added sectors.

However, it is important to note that this facility is not unique in those challenges.

All of the recent reports illustrated the continuing problem of mental healthcare being provided in unsuitable buildings.

Staff shortages

The Inspector’s report also mentions the lack of staff at facilities. At the Eist Linn child and adolescent facility, staff, particularly medical staff, felt they were under-resourced. There were 1.8 WTE dedicated consultant psychiatrists and 0.8 WTE NCHDs for the approved centre. The staffing recommendation for Child and Adolescent inpatient units in A Vision for Change is for two medical staff.”

But it was also emphasised that “the approved centre provided a good quality of service to young people from the HSE South”.

Speaking to the Medical Independent (MI), Dr Susan Finnerty, Acting Inspector of Mental Health Services at the Office of the Inspector of Mental Health Services, says the reports show there are a few areas that require attention.

“In this batch of reports of 2014 of approved centres, there are a few issues that require attention. The importance of each resident having an individual care plan (ICP) has been highlighted by the Mental Health Commission and the Office of the Inspector of Mental Health Services since 2006. The ICP is the foundation of a service user’s pathway through the mental health services and should be developed by the multidisciplinary team in conjunction with the service user.

“It is disappointing that some services still have difficulty in achieving full compliance with ICPs,” Dr Finnerty continues. “The Mental Health Commission has produced a Guidance Document on Individual Care Planning for Mental Health Services and this is available in all approved centres.”

Dr Finnerty goes on to explain the importance of legible prescriptions and the correct and consistent use of Medical Council registration numbers: “There were concerns about the prescriptions and administration of medication within approved centres across the state,” she tells MI.

“In a significant number of approved centres, doctors were not using their Medical Council Registration numbers when writing prescriptions. This is required under the Mental Practitioners Act 2007. Some prescriptions were illegible, discontinuation of medication was not signed or dated and, in a small number of cases, prescriptions were not signed. In a number of approved centres, administration of medication sections were left blank so that it was unclear whether the resident had received their prescribed medication.

“All of these factors increase the risk of medication errors. The inclusion of pharmacists, in some approved centres, on multidisciplinary teams, in providing information for residents and advice for doctors is very welcome.

Quality improvements

“Inspections of mental health services are important for ongoing quality improvement, which all services are engaged in. Inspection reports allow mental health services to monitor their progress and are also important in highlighting areas of good practice, as well as areas for improvement.”

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Dr Matthew Sadlier

Dr Matthew Sadlier of the IMO’s Consultant Committee tells MI that the issue of prescription legibility may be more applicable to community pharmacies.

“In the hospital setting, there a limited number of doctors who are prescribing anyway,” he says. “However, requirements are requirements and yes, doctors should be adhering to Medical Council guidelines and it should be part of their induction and training. In the same way, there’s very little excuse for illegible handwriting. But there are some simple solutions to this.”

Dr Sadlier adds that in some hospitals in which he has worked, doctors have been furnished with stamps containing Medical Council numbers and names. He also sees electronic patient records as an important way to avoid many of the issues highlighted in the Inspector’s reports.

“Most general practices around the country now use electronic prescribing,” he tells MI.

“I would go so far as to say it’s bizarre that in 2015, we are not using electronic patient records, which has so many advantages in terms of patient safety and automatic prompts. This could eliminate so much potential for simple human error, such as a spelling mistake that could confuse one medication with another.”

He also touches on the issue of confidentiality, which has been raised by some as a factor that causes resistance to the move towards electronic patient records.

“Electronic data falls under the auspices of the Data Protection Commissioner. Through the IMO, I have called many times for health information and patient records to have a separate set of legislation from the Data Protection Act, which is there mainly to cover commercial data. While obviously requiring the highest confidentiality, commercial and patient data require different levels of safeguards and access. I think it’s critically important to have a Health Information Bill and that health information is exempted from the Data Protection Act or is brought into a supplementary Act, such as a Health Data Protection Act.”

The former IMO President comments: “If I’m working in AIB, for example, there’s no reason why I should be able to get information from Bank of Ireland on a customer’s account. However if I’m working in Cork University Hospital and a patient needs to attend a hospital in Dublin, in such cases there should be a national, integrated patient information system where protocols are in place whereby a doctor could access that patient’s records. That would solve any prescribing issues and make prescribing safer and neater.”

Dr Sadlier commends the doctors in mental health facilities and outlined some of the key issues they face in day-to-day practice. “There has been some infrastructural spend and there have been some new units built, but one of the difficulties — and this applies in many mental and physical health settings — is that you’re trying to apply 21st Century technology in a 19th Century building,” he tells MI.

“These buildings were designed in a different era, where patients were treated differently, so we are trying to retro-fit the modern concepts of privacy and dignity to buildings with shower facilities and common rooms from a different era.”

Balancing act

In terms of dignity and privacy for patients, he states: “On the one hand, there are issues of patient safety and security and on the other hand, there is a very vulnerable patient group, in a time of crisis who often need a high level of observation. To marry these two things is always a very difficult balancing act.

“It can be seen in some of the newly-built units that there are ways of facilitating that and they have, for example, doors that open inwards into the patient’s room and the patient is allowed to close the door, or door systems with release keys, two-way intercoms in the patient’s room, and so on. In the more modern architecture, these needs are taken into account but in the older buildings, these weren’t considerations and that means that getting that balance between dignity, privacy and safety and observation can be a more difficult balancing act.

“I would have a lot of sympathy for the doctors running these facilities and indeed for anyone in the health service, because the budgets are just not there to build brand new buildings every 10 years.

“Nobody is against the concepts of quality and safety, but with every quality and safety initiative that is introduced, it requires more manpower and resources and that puts pressure on the service,” he continues. “For example, the Integrated Care Plans are entirely justifiable and I’m not against them, but they do take up more staff time.

“In reality, in the old days people had caseloads that were far too big and were managing these caseloads by engaging in practices that were sometimes not of the highest levels of quality and safety. Quality and safety initiatives are important, but the fact is that they do require more form-filling and reporting of incidents and these all take time. That means that the caseload that each individual staff member can manage must reduce, because they are now spending more time on each case.”

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