The Mental Health Commission is to issue legal proceedings against Cork University Hospital (CUH) over an “unprecedented” level of critical non-compliance with regulations in its adult mental health unit.
The commission published 10 inspection reports on various inpatient mental health centres on Tuesday.
The watchdog said it found the CUH mental health unit to be compliant with 61 per cent of regulations during an inspection last April, slightly above the 58 per cent compliance noted in 2023.
The unit was deemed to be critically non-compliant in eight areas, which the inspector said was “unprecedented”. The watchdog also said the 50-bed centre was in breach of a condition of registration, namely an order to submit a quality improvement plan to the commission.
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It is an offence to breach a condition of registration, with the commission describing the situation as “deeply concerning”.
It is understood that the commission intends to initiate additional enforcement action against the unit, with proceedings expected to come before the courts in the coming weeks.
During the unannounced inspection, which took place from April 9th to 12th last, the inspector was “not assured that minimum standards of safe, effective, high-quality, person-centred care and treatment was being provided in the approved centre”.
The inspection team said there were “serious concerns” around a number of issues including access to therapeutic services, general health of residents, staff training and risk management, among others.
Two serious reportable events were notified to the commission since the last inspection. However, five events that met the criteria for notification occurred during that time frame.
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Serious reportable events, which must be notified to the commission within 48 hours of them occurring, include a sudden or unexplained death of a patient, a serious disability occurring, or the sexual assault of a patient or other person on the grounds of the healthcare facility.
“Therefore, three events were not notified. This is a serious concern,” the report said.
The inspector noted structural risks, including ligature points, which they said were not removed or effectively mitigated. There were also “deficits” identified in the implementation of the code of practice on the use of physical restraint.
In one instance, there was no medical exam conducted of the person post restraint, one instance where no debrief was conducted, and one instance where no review of the episode was conducted with the resident.
Cross-discipline staff shortages were also highlighted by the MHC. Some 1.5 whole time equivalent clinical posts were vacant at consultant psychiatrist grade, while there was no dedicated occupational therapist for the centre.
“Community-based occupational therapists provided input in certain circumstances (such as pre-discharge assessments), but effectively residents were without occupational therapy involvement for their stay in hospital,” the report said.
Residents had access to an outpatient physiotherapy clinic in Cork University Hospital. However, the MHC said this was not suitable for residents detained under the Mental Health Acts 2001-2018 or residents with significantly impaired mobility.
There were 10 nursing vacancies, covered by overtime and use of agency nursing staff. No dietitian was available to residents internally or externally and there was “evidence that residents had weight management issues, unexplained weight loss or weight gain while in hospital”.
As a result, residents’ dietary requirements were not regularly reviewed by a dietitian, which impacted the risk of further malnutrition, the report added.
Asked about legal proceedings being issued, a spokeswoman for HSE South West said it is “committed to delivering the highest possible standards of care for patients”.
“We take the observations contained in the reports seriously and are actively working with the Mental Health Commission in progressing corrective action plans to ensure all requirements are met,” she said.
