Month: January 2022

Review published into South Kerry Child and Adolescent Mental Health Services

https://www.irishtimes.com/news/health/hse-report-finds-hundreds-of-children-received-risky-treatment-from-doctor-in-south-kerry-1.4785707?localLinksEnabled=false

By Paul Cullen for Irish Times

Hundreds of children received “risky” treatment from a doctor working in mental health in South Kerry and significant harm was caused to 46 of them, a report has found.

The review into allegations that young people who attended mental health services in South Kerry were prescribed inappropriate medication was published by the Health Service Executive on Wednesday morning.

The review has examined the treatment of more than 1,300 young people who attended the South Kerry Child and Adolescent Mental Health Services (Camhs) over a four-year period.

The risks involved in the treatment by the doctor included sleepiness, dulled feelings, slowed thinking and serious weight gain and distress, according to the review.

Having reviewed 1,332 files, the authors of the report found no extreme or catastrophic harm was caused to the patients in these files.

Not all of the children who the doctor worked with were put at risk of harm, they found.

The care and treatment of 13 other children by other doctors was also risky, the review has found, and the authors found proof of significant harm to 46 children.

This harm included production of breast milk, putting on a lot of weight, being sleepy during the day and raised blood pressure.

Enumerating the key causal factors behind events, the review said the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) for secondary school children was often made “without the right amount of information from their teachers on how the children were at school”.

Checks of observations of unwanted effects of medications “did not happen”, including pulse, blood pressure, and height and weight.

“These observations were not regularly checked or not recorded properly. Necessary blood tests were not always done. The doctor was not available for interview.

“We believe that the Doctor thought they were helping the patients and did not intend to harm the patients they treated.

“The exposure of the children to risk and harm by the Doctor was because of lack of knowledge about the best way to do things.”

The review also identified key contributory factors including the fact there was no clinical lead for the Camhs Area A Team. “This was one of the reasons for failing to provide and keep a high quality service.”

In addition, there was no consultant child and adolescent psychiatrist from 2016 for the Camhs Area A Team.

While another consultant child and adolescent psychiatrist agreed to cover the vacant post until it was filled, it was expected that it would only be for a short while.

“It took much longer than expected to find someone to fill the vacant position. Not enough attention was paid to the possible risks while this job was vacant.”

The consultant psychiatrist supervising the doctor did not see problems that developed throughout 2017 and 2018.

Concerns about the doctor were first reported in 2018, but no proof was found that these concerns were addressed after being reported.

In 2019, concerns about prescribing medication were clear, according to the report, and the supervisor at the time advised changes but did not insist these happened.

The doctor worked extra hours and was observed to be very tired at work, but this issue was not addressed.

There was no system used to check the prescribing of medications or the quality of service by the doctor’s supervisors, the review states.

In 2020, the doctor was recommended for other jobs even though there was concerns about the doctor.

And while a new senior medical manager started in the service, the concerns about the doctor were not handed over to this person.

According to the review, the service has not put in place many of the recommendations of the National Camhs Operating Procedure 2015 or the Camhs Operational Guideline 2019.

It did not have updated treatment plans that are shared with the patient their family and the person who referred them to Camhs, nor did it name a key worker in all cases, a team coordinator or a practice manager.

The Camhs Area A Team had a lot more referrals of new patients than other areas across the country, and this had not reduced at the same rate as other services.

Some of the referrals which were not accepted were not dealt with quickly and were left awaiting on a decision of acceptance.

There was no shared diary and reception staff did not know who was coming in for appointments. “Staff cannot quickly know who is working on a case. All of this means cases get lost.”

Rules on looking after case files were not being followed properly. Staff and doctors were able to take files from the file room without signing them out, against HSE policies on the management of health records.

In addition, clinical information was not always recorded in the patient file.

The review said there is proof of two missing referrals and 10 full case records, which have been reported in line with data protection rules.

While the Camhs has a governance group, this did not check it was working safely and effectively, or talk about the risks of a long term vacancy.

The review made 35 recommendations, including:

– Children and their families should be invited to be part of the governance structure of the Camhs service.

– The recruitment of a permanent full-time clinical lead consultant psychiatrist must remain a priority for the service.

– community healthcare organisation managers in the HSE should think about setting up a working group to look at the current and future needs of Camhs.

– Training for all staff in risk and incident management. “Across Ireland, the head of the CHOs and the senior doctors should be told about the risks for their teams which have not had consultants for a long time.”

Responding to the review, the HSE repeated earlier apologies it has made to the 46 young people and their families who suffered serious harm, and to all 240 young people “who did not receive the care they should have”.

“Young people and their families are entitled to expect a high standard of care when they attend our services, and the report makes it clear that this did not happen in a large number of cases,” Michael Fitzgerald, chief officer of Cork Kerry Community Healthcare, which has responsibility for HSE mental health services in Kerry, said.

“As chief officer of the organisation, I apologise sincerely to the young people and their families for this. I want to reassure the young people and their families that we have taken on board the 35 recommendations in the report, and will implement them as quickly as we can.”

The review team was led by an external Camhs consultant, Dr Seán Maskey, from the Maudsley Hospital in London, who travelled to Ireland to carry out this work.

The HSE has already apologised to about 250 families for substandard care identified in the review.

The review was prompted by concerns expressed by a whistleblower in the health service who alleged substandard treatment of clients of South Kerry Camhs.

The HSE initially looked at the files of about 50 young people who attended the service, after which it was decided to carry out a “look-back” review of all files between July 2016 and April 2021.

Diagnosis and notes
The review, which was conducted by a team led by Dr Seán Maskey, a consultant child and adolescent psychiatrist based in London, examined allegations of inappropriate prescribing of medication as well as issues around the diagnosis of patients and missing notes. It is also expected to deal with resource issues at the service.

The report was being posted to affected families on Tuesday, and a copy has been sent to Minister for Health Stephen Donnelly.

“We ask for the time and space to communicate directly with the young people affected, as we have done on an ongoing basis since last April when the review process began,” Cork Kerry Community Healthcare said in a statement.

Apology repeated
“We will not be making any further comment until young people and families receive the report, other than to say that supports are in place for those affected, and that we are committed to acting on all recommendations in the report.

“Where the review identified deficits in the care of any young person, we have apologised directly and sincerely to that young person and, where appropriate, their family. We are repeating that apology in writing as part of the publication process.”

“We sincerely thank the young people and families who took part in the review process, and we do not underestimate how difficult this has been for them.”

The HSE is operating an information line for those affected – 1800 742 800 – which is open from 8am to 8pm, seven days a week.

Marathon runner and mother-of-one Sandra O’Brien (55) was among 72 people who got sick in outbreak linked to cold cooked turkey supplied by catering company

by Andrew Phelan

https://www.independent.ie/irish-news/courts/i-knew-straight-away-she-was-dead-husband-tells-of-finding-his-wife-lifeless-in-bed-after-food-poisoning-at-communion-party-41248337.html

A “VIBRANT and healthy” mother of one died of food poisoning after eating contaminated cold cooked turkey at her grand-niece’s communion party, an inquest heard.

Sandra O’Brien (55) died in her bed eight days after contracting salmonella from food provided by outside caterers at the family gathering.

Her husband said his wife had been a marathon runner and told the inquest of his shock at her death, after what was described by a pathologist as a “very rare event”.

Dublin Coroner’s Court heard Ms O’Brien died of acute myocarditis, or inflammation of the heart muscle, secondary to salmonella infection.

Hers was the only death in an outbreak of 72 cases linked to parties in north Co Dublin over two days in 2017.

A jury returned a narrative verdict in the case today.

Coroner Dr Clare Keane sympathised with the family on the “devastating and untimely loss” of Ms O’Brien, a “vibrant and healthy woman who was in excellent physical condition prior to her death”.

Ms O’Brien, from Rivervalley, Swords, Co Dublin, died on May 21, 2017, following the consumption of food prepared by a catering company working from O’Dwyers Pub, Strand Road, Portmarnock, Co Dublin.

The court heard the catering company Flanreil Food Services has since been fined for food safety breaches.

Ms O’Brien’s widower Michael O’Brien, a Garda sergeant, said in his deposition he and his wife had been married for 27 years before her death.

On May 13, 2017, they attended their grand-niece’s communion party in Ballyboughal, north Co Dublin. Food was supplied by an outside caterer, he said in the deposition, which was read out to the court.

His wife ate some of the cold meat that was at the party. Two days later, on May 15, they were shopping to purchase clothes for a cruise his wife was going on with family.

She complained of feeling unwell and they went to a cafe to sit down and have a coffee. She still felt unwell and they returned home, where she began to vomit and feel weak. Ms O’Brien went to bed and was sick on a number of occasions, he said.

Mr O’Brien went to work and his wife said she would be OK, but she later called him and said her condition was worse and that their grand-niece was sick in Temple Street hospital.

Mr O’Brien went home to find his wife vomiting, and he took her to Beaumont Hospital.

After a five-hour wait, she was seen by a doctor, who said he had a gastro-intestinal infection. Ms O’Brien was put on a saline drip. Mr O’Brien said he got blankets for his wife as she was “very cold”.

At 7am on May 16, she told him to go home and get some sleep while she was treated. She later rang him to pick her up so he collected her. Once home, she went straight to bed. However, her vomiting and diarrhoea continued.

The hospital called to say she had contracted salmonella and she was advised to stay hydrated. Medication to treat food poisoning was prescribed through her GP and Mr O’Brien collected this.

For the next few days while she took the drugs, her condition did not improve, and the hospital rang a number of times to check her condition.

On May 20, Ms O’Brien told her husband she was feeling a little better and had some soup – the first food she had eaten since the previous Monday.

She went back to bed and later got up and had a cup of tea when her sister called to the house.

“Sandra was in good form and her condition seemed to improve,” Mr O’Brien’s deposition continued.

The following morning, he got up at 6am: his wife appeared to be asleep in bed and he went to work. Later he rang her but got no answer. He rang again and tried the house phone but assumed she was too tired to answer and decided to let her sleep.

Mr O’Brien got home at 3.15pm and noticed the blinds were still pulled down, which he thought was strange.

When he entered the house he called his wife’s name but got no reply. He went up to find the bedroom in darkness. He could make out that she was still in the bed. Her eyes were closed and when he touched her face it was very cold.

“I knew straight away she was dead,” he said.

Her hands were under her head as if asleep. Mr O’Brien was shocked, and rang for an ambulance which arrived.

Family members, including their son Josh, then arrived and it was “most distressing for all of us”.

Mr O’Brien then answered the coroner’s questions.

He confirmed that the shopping trip on May 15 had been the first indication that his wife was unwell, and she complained of pain in her stomach.

“She was a tour de force when it comes to fitness,” he said of his wife.

Even before they met, Sandra was in running clubs, he said; she ran marathons, was a member of a gym and attended fitness classes.

“She was an extremely fit girl,” he said.

When his wife called him at work, she had said she needed to go to hospital straight away.

“I knew something was seriously wrong – she was so fit and healthy,” he said.

By May 20, she had seemed in better spirits, he said.

Some time during the night, he believed, she passed away beside him “unbeknownst to myself”, and he got up in the morning and went to work.

Josh O’Brien said his mother was in good form and it seemed like the food poisoning had passed when he spoke to her the day before she died. The next morning she “didn’t stir” in bed when he said, “See you later.”

Nicola Judge, Sandra’s niece, said 30 people attended her daughter’s communion party and 17 got sick, including her daughter.

When Mr O’Brien told her Sandra had died “it was a big shock because she was so fit and healthy” and had “at least 10 marathons under her belt”.

Helena Murray, a public health specialist at the HSE, said she chaired the outbreak control team.

Death from salmonella brandenburg was rare, with a 0.5pc mortality rate, she said.

The outbreak arose from parties that took place on May 13 and 14. Of these, 1,553 people attended 16 parties on May 13 and 105 on May 14.

She said the premises was served with a closure order under food safety regulations on May 19 as it was deemed to be a grave and imminent danger to public health. Later this was lifted, allowing the business to reopen. When it was inspected again, food safety management requirements were being adhered to.

In the outbreak, there was a total of 72 cases with 35 confirmed and 37 probable cases. Most had attended the off-site parties on May 13 and 14, and there were four kitchen staff and food handlers affected.

The number of cases was small relative to the number of parties, Ms Murray said. Cold cooked turkey was found to be the main and only contaminant.

The group’s report made recommendations on the use of social media for information and advice during outbreaks.

There should be guidance on the appointment of a family liaison for outbreaks.

The report also made recommendations on measures to be taken before the nature and extent of any food business is increased. There should be guidance to businesses on the risks associated with event catering, it found. The group stressed the importance of excluding ill food handlers from work for 48 hours.

Pathologist Avril Cullen said the cause of death was acute myocarditis secondary to salmonella infection.

This was described in literature as a “very rare event,” she said. There were also signs of previous episodes of myocarditis, she said.

Garda Kevin Barry said the directors of the food company Flanreil, Rory Reilly and Ciaran Flanagan, were convicted following an investigation and district court prosecution for breaches of food safety regulations.

Fines totalling €18,400 were issued against them and the company.

The jury delivered a narrative verdict, a factual summary, stating that Sandra was a “fit and healthy woman” who attended a communion party where she contracted salmonella through food provided by a catering company. Despite attending hospital and receiving treatment, she subsequently died, the verdict concluded.

The jury also endorsed recommendations made in the report of the outbreak control team.