Major concerns identified in child mental health services

The inspector of mental health services has expressed serious concerns about the care provided to young people by Child and Adolescent Mental Health Services (CAMHS).

According to Dr Susan Finnerty, while CAMHS staff were found to have worked extremely hard and many young people have received excellent care and treatment, major concerns were identified including long waiting lists, children “lost” to follow-up care and a lack of monitoring of antipsychotic medication.

The details were included in an interim report arising from an independent review of the provision of CAMHS that was carried out by the inspector of mental health services in 2022. The interim report focuses on five out of the country’s nine community healthcare organisations (CHOs).

It revealed that there was a big variation in waiting lists in different CHOs, however, across its sample of clinical files, 28% of children were waiting for more than three months for an assessment appointment, while 4% were waiting for over one year.

The report emphasised that many young people and their families are “frustrated, distressed and are trying to cope with deteriorating mental health difficulties while waiting for lengthy periods for essential services”.

It also noted the frustration of GPs who are attempting to get a child assessed, but are “having to resort to sending a child to the emergency department (ED) in local hospitals to obtain a psychiatric assessment”.

The report also expressed serious concern about the number of young people with open cases who have been “lost to follow-up”.

“This means that children who should have had follow-up appointments, including for review of prescriptions or monitoring of medication, did not have an appointment, in some cases for up to two years. These included some who had reached their 18th birthday with no planning, discharge or transition to adult services or any advice about medication. For one team, there had been 140 lost cases,” the report highlighted.

The monitoring of medication was also a cause of concern. There was evidence that some CAMHS teams were not monitoring the use of antipsychotic (neuroleptic) medication in accordance with international standards (there are no national standards).

As a result, some children were taking medications without appropriate blood tests and physical monitoring that is deemed essential when using these drugs.

Meanwhile, the report also noted that audits of clinical practice were hit and miss, with three of the five CHOs “rarely” carrying out audits, but two of the five CHOs displaying “elements of good auditing practice”.

When it came to clinical files, four out of the five CHOs still used a paper-based system and these paper-based files were “frequently disordered, incomplete, sometimes illegible, with little logic to the filing of documents within them”.

Staffing was also a major issue, according to the report, with all teams found to be below recommended staffing levels. Some were 50% below recommended levels. Some teams had no consultant psychiatrist and were covered by a number of different consultants, “resulting in confusion and frustration among members”.

The report also pointed out that some CAMHS facilities are housed in old buildings, “some of which are unsuitable, poorly decorated and too small…with a lack of clinical space, lack of sound-proofing and insecure places for storing clinical files”.

Within the interim report, Dr Finnerty made two immediate recommendations to the HSE and the Minister for Mental Health:

-An immediate clinical review of all open cases in all CAMHS teams, with particular focus given to identifying and assessing open cases of children who have been lost to follow-up and physical health monitoring of those on medication

-That the Minister for Mental Health ensures, as a priority, that there is immediate regulation of CAMHS, under the Mental Health Act 2001.

According to the CEO of the Mental Health Commission, John Farrelly,  this report “shows clear failings of governance and oversight with no evidence that a national coordinated approach is being taken to caring for children with a mental illness”.

"Our core concern should be for the health and welfare of these children and the priority now for the HSE must be identifying and safeguarding the children lost to follow-up,” he commented.

He said that the CEO of the HSE “has committed that the HSE will immediately conduct a review of all open cases”.

Responding to the report, Mental Health Reform, which is a coalition of mental health organisations working to improve services in Ireland, described it as a "damning indictment of the deepening crisis in our mental health services".

"The crisis in CAMHS requires a national coordinated response. There is a fundamental need for greater accountability and oversight across the health service. We are calling for the reinstatement of a national director for mental health in the HSE who would report directly to the CEO of the HSE. There has been no national director since 2016 depsite the current Programme for Government containing a commitment to reinstate the position," commented Mental Health Reform interim CEO, Róisín Clarke.

The interim report involved the following five CHOs:

-CHO 3 (Clare, Limerick, north Tipperary/east Limerick)

-CHO 4 (Kerry, north Cork, north Lee, south Lee, west Cork)

-CHO 5 (south Tipperary, Carlow Kilkenny, Waterford, Wexford)

-CHO 6 (Wicklow, Dun Laoghaire, Dublin southeast)

-CHO 7 (Kildare/west Wicklow, Dublin west, Dublin south city, Dublin southwest.)

The inspector’s review of the remaining four CHOs is continuing. These are:

-CHO 1 (Donegal, Sligo/Leitrim/west Cavan, Cavan/Monaghan)

-CHO 2 (Galway, Roscommon, Mayo)

-CHO 8 (Laois/Offaly, Longford/west Meath, Louth/Meath)

-CHO 9 (Dublin north, Dublin north central, Dublin northwest).

Dr Finnerty’s final report on CAMHS is due for publication later this year. The interim report can be viewed here.