Underlying causes of child mental health care scandal wider than one errant doctor

The actions of a single errant doctor are largely to blame for shortcomings in care provided to hundreds of vulnerable children with mental health issues in South Kerry, but the underlying causes of this scandal are wider-ranging.

For as long as the health service depends so heavily on junior, temporary staff, often working without adequate supervision and overloaded with cases, catastrophic errors will continue to occur. The Health Service Executive is suffering an ongoing crisis around the recruitment and retention of qualified staff that is certain to lead to more disasters into the future.

But the shocking findings of this review into South Kerry Child and adolescent mental health services (Camhs) also raise questions about the approach being taken by some health professionals as mental health disorders rise among young people. There is clear evidence from the review of diagnoses being made too quickly, of inappropriate prescribing and of the over-reliance on medication to deal with patient challenges.

As the review states: “The medicalisation of ordinary emotional responses in children and their suppression by medication, risks delaying or damaging the development of skills in the self-regulation of emotions which normally happens as children mature.”

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The doctor at the centre of the controversy worked in the service between 2016 and 2020 as a non-consultant hospital doctor (NCHD). He was a locum who worked on a HSE contract and, at other times, through a private agency.

There were plenty of missed opportunities to intervene at an earlier stage; this was also a systems failure, from senior management down.

Things were already going awry in 2016, at the time the doctor at the centre of the controversy started work in Kerry. Staff had complained to senior management about the lack of a consultant presence at meeting, the backlog of clients awaiting diagnosis and another backlog of young people awaiting medication reviews.

At this stage, there were over 320 open cases, 130 needing follow-up and 54 patients waiting for a discharge letter. The service wasn’t coping.

“NCHD1”, as the doctor is referred to in the review, was not engaging with professional competence requirements and was said to be isolated and “micromanaging patients with medication”. One of his patients had died by suicide and he was reported to have been very distressed. He was also doing outside work, further contributing to his fatigue and stress.

Concerns about the doctor were first reported in 2018, but do not appear to have been addressed. In 2019, a colleague became concerned about his prescribing practices and efforts were made to improve his performance. The supervisor at the time advised changes but did not insist these happened, according to the review.

It was only in September 2020, when a new consultant psychiatrist arrived and blew the whistle, that meaningful action was taken. By then NCHD1 had left the service.

The subsequent investigation process, which included a look-back at cases and meetings with families as well as the just-published review, appears to have been thorough.

Child psychiatry is not the only service to have been buffeted by the Covid-19 pandemic and even the cyberattack on the HSE last year. But the impact on Camhs has been far greater than in other parts of the health service due to soaring demand and massive under-staffing.

One Dublin hospital saw a trebling of Camhs referrals earlier in the pandemic. Meanwhile, one-third of psychiatric posts are not permanently filled, 20 per cent are vacant for more than three years.

Against this background, the nationwide review of Camhs services signalled by the Taoiseach on Wednesday is likely turn up further issues of concern.