At the end of January, the Health Service Executive published the Maskey Review which examined the mental health treatment received by children and adolescents in South Kerry. The review showed hundreds of patients had received risky treatment with 46 having suffered significant harm as a result. The review, which comes after allegations that young people were given unsuitable prescriptions, examined the treatment received by over 1,300 patients who have attended the South Kerry Child and Adolescent Mental Health Service (CAMHS) between July 2016 and April 2021. The review was lead by an external CAMHS consultant from the Maudsley Hospital in London, Dr Seán Maskey.
The risks associated with the treatment administered by a non-consultant hospital doctor in the Area A clinic involved unreliable diagnoses, inappropriate prescriptions, poor monitoring of treatment, and adverse effects such as daytime-sleepiness, dulled feelings, slowed thinking, weight gain and distress. The harm caused to the 46 patients materialised, in some instances, into the production of breast milk, significant weight gain, day-time sleepiness and raised blood pressure. The doctor did not co-operate with the review and was allegedly also working in a private clinic and running a private practice. The treatment of 13 other children by other doctors in the CAMHS service was also deemed to be risky. In one instance, a child was prescribed three types of medication for ADHD, which he took for over two years, with drastic negative effects on his quality of life.
Taoiseach Micheál Martin stated there will be a nationwide audit into the compliance with Child and Adolescent Mental Health Services guidelines of the 72 CAMHS teams currently in operation. Mr Martin classed the results of the HSE review as shocking and unacceptable. He stated that “a complete failure of clinical performance” and “a systemic collapse … in terms of overall clinical governance” caused the first principle of medicine – to do no harm – to be breached.
The Taoiseach also underlined the wider issue around recruitment of qualified personnel, stating “we need to face up to” it. The CAMHS Area A team did not have a clinical lead. There was also no consultant child and adolescent psychiatrist since 2016. The doctor was visibly tired and had worked extra hours. Concerns about the doctor started coming in 2018 but were not handed over to new senior management in 2020.
The review brought to light the fact that the service did not observe the CAMHS Operational Guideline 2019 and did not institute the National CAMHS Operating Procedure 2015. HSE policies on management of health records were also breached, as personnel were able to take files from the file storage room without signing them out. The CAMHS governance group reportedly did not check the safe working of the Area A Team and did not advise on the risk of a long-term vacancy.
Róisín Shortall, Social Democrats co-leader and the Dublin North-West TD described the review as “shocking and distressing” for the concerned families, while also pointing out that the treatment of the whistleblower in this case, a former locum consultant psychiatrist, raises serious issues in regard to the treatment of whistleblowers in State institutions. The report was posted to the families involved and a copy was sent to the Minister for Health Stephen Donnelly.
The HSE issued apologies to the affected families, and notified the Medical Council, which may sanction doctors found to have breached professional standards. The findings were also referred to An Garda Síochána who may take up a criminal investigation.
The review can be read here.