Mental Health Commission: too many residents still being treated like ‘second-class citizens’

Mental Health Commission: too many residents still being treated like ‘second-class citizens’

Mental health residents being treated like 2nd class citizens

The Chief Executive of the Mental Health Commission has said that too many mental health residents in Ireland are still being treated like second-class citizens whose fundamental human rights continue to be overlooked.

The Commission’s 2019 Annual Report - which has been published today – shows that while overall average national compliance with regulations was recorded at 78%, many mental health residents are still being admitted to outdated and unclean premises without a meaningful care plan essential to their recovery. The report also found an increase in the number of approved centres that used physical restraint, while there was just 21% compliance with rules around seclusion.

“This year’s report once again demonstrates that the needs and wants of mental health service users are not being prioritised,” said John Farrelly. “The Commission has consistently and repeatedly underlined the failings in our mental health system year after year, yet these shortcomings are yet to be acted upon in any meaningful way.

“The report evidences that our mental health service users are still being treated like second-class citizens in this country. We may have made huge strides since we started to shut down the old mental hospitals, but it’s abundantly clear to the Commission that we haven’t come far enough. The basic human rights of many residents continue to be overlooked.

“While our enforcement proceedings are resulting in some progress, it is clear that there are a number of matters that are key to addressing these issues,” added Mr. Farrelly. “There must be ring-fenced funding for mental health; the refreshed vision must, unlike the previous strategy, be fully implemented; the current Mental Health act must be reformed; and there needs to be a cultural change amongst those providing services.”

Some of the starkest findings in the report are included in the annual review of services by the Inspector of Mental Health Services, Dr. Susan Finnerty. This review shows that 45 of the 65 (69%) in-patient centres were non-complaint with the regulation on premises, many because they were unclean or were suffering from poor structural or decorative conditions.


“It is clear in my annual review - as it has been in previous years - that a significant number of our premises are no longer suitable and need to be replaced,” said Dr. Finnerty. “Of the 69% of in-patient units that were non-compliant with this regulation, 33% were dirty. Findings included a dirty seclusion room, unclean bathroom facilities, litter in outdoor areas and offensive odours. Ten approved centres were not adequately lit, heated, or ventilated. This is an ongoing problem, year on year. It is simply not good enough that people who are extremely unwell are forced to reside or recover in wards or rooms that are unclean, malodorous or poorly maintained.”


The report also shows a pattern of poor practice in relation to seclusion and physical restraint. Almost 80% of centres that used seclusion were non-compliant, while just half of the 58 centres that used physical restraint were compliant with the relevant code of practice.

The review also demonstrated clear evidence that there remains an ongoing failure to provide all residents with a meaningful individual care plan - a document that is essential to person-centred, recovery-based care – with 31 centres non-compliant in this area.


“Continued poor compliance with the regulation on individual care plans needs to be tackled on a number of fronts,” said Dr. Finnerty. “Perhaps most importantly, there needs to be a change of culture. The patient’s care plan should be seen as the blueprint for their care pathway. And it should be viewed as the patient’s care plan, not the clinician’s.”


The report also showed that compliance in relation to the regulations on staffing was recorded at just 8%. “The non-compliance here relates predominately to staff training,” said Mr. Farrelly. “While compliance is very low, we have noted from our audits that most centres were making good progress in this area. However, this is something that we will be keeping a very close eye.”


The Commission has written formerly to the HSE seeking an action plan to address the significant issues raised in their report, and particularly around premises, seclusion and restraint, staffing and individual care plans.


Both Dr Finnerty and Mr. Farrelly complimented the quality of care offered by staff. “Once again, staff were observed to be kind, compassionate and caring towards residents, and this is something that we have all seen once again during the recent pandemic,” said Dr. Finnerty. “It was also notable that the best services improved their quality of care by working in partnership with the service users and empowering their staff.”



Enforcement action is taken where the Commission is concerned that an element of care and treatment provided in an approved centre may be a risk to the safety, health and wellbeing of residents, or where there has been a failure to address an ongoing area of non-compliance.


The report shows that the Commission took 40 enforcement actions against incidents, events and serious concerns that arose in 2019 and related to 31 centres. These included issues relating to premises, staffing and the privacy and dignity of residents, and the first ever prosecution under the current Mental Health Act on foot of findings that patients were deprived of basic dignity and human rights by being secluded in a dirty, malodorous, badly-lit and badly-ventilated room.

Forty-five per cent of enforcement actions arose from regulatory inspections conducted by the Inspector of Mental Health Services. Forty-three per cent of enforcement actions arose from compliance monitoring and in particular pre-registration compliance monitoring.


Implementation and reform

The Chairperson of the Mental Health Commission, John Saunders, said that the report provides perhaps the clearest evidence yet that the new government must commit to ensuring the full implementation of the refreshed mental health policy, and that this implementation should commence without delay.


“If we want to see real change, the new government must implement the refreshed policy in full and this must be met with ring-fenced and prioritised funding,” he said. “It is also critically important that we push forward and repeal and replace the current Mental Health Act to reflect a human rights approach. These reforms must include enhanced powers so the Commission can appropriately regulate all community, online and other forms of care and treatment.


Decision Support Service:

The annual report also detailed the work undertaken during 2019 to support the roll-out of a fully-operational Decision Support Service (DSS). Work during 2019 included engagement with a wide range of stakeholders to provide information and promote readiness for commencement of the Assisted Decision Making (Capacity) Act 2015; developing the operational structures necessary to deliver an accessible person-centred service; reviewing Code of Practice; and growing the DSS team.


“Significant progress was made collaboratively with the Department of Justice and Equality and the Department of Health towards the end of 2019 towards agreeing a costed, time-bound plan for commencement that all interested parties could work towards,” said the Director of the Decision Support Service, Aine Flynn.


You can find a link to the report here: MHCAnnualReport_2019.pdf

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