The HSE says it is making service improvements to ensure that all unexpected deaths in mental health services are reported on and investigated properly by local staff.

Audits carried out by the HSE have revealed serious shortcomings in the manner in which deaths likely to have been from suicide were handled in both community mental health services and approved treatment centres.

irishhealth.com revealed yesterday that in a recent audit of 21 sudden unexplained deaths in community services it was found that 50% of the cases examined had not been investigated or reviewed by the service and only one in five of the deaths were notified in accordance with regulations.

A separate audit found flaws in the manner in which sudden unexplained deaths in mental health treatment centres were investigated by staff. It said care or service delivery problems were generally not highlighted in the investigation of 12 deaths audited, in accordance with guidelines.

The HSE, in response to the audit findings, told irishhealth.com that it is taking steps to ensure that recommendations for improvements made in the audits on the notification, recording and investigation of sudden unexplained deaths in mental health services are addressed.

A spokesperson said the National Director of Mental Health Services recently issued a memorandum to all relevant managers, re-emphasising the requirements in relation to the reporting of sudden unexplained deaths.

The HSE said work is under way in conjunction with the Mental Health Commission in respect of two recommendations and it is working to ensure that the other shortcomings identified are addressed through appropriate performance management and service improvement processes.

Work is also ongoing in relation to the provision of systems analysis training being provided to mental health staff across the system, the HSE added.

The audits were carried out in 2013 and in early 2014.

The audit report on the community service deaths concluded that, based on the information submitted, the audit team could not provide assurances that incidents of sudden unexplained death of persons in community mental health services were being notified in accordance with HSE policy and procedures, nor could it provide assurance that incidents of this nature were investigated using the systems analysis methodology.

Meanwhile, junior health minister Kathleen Lynch, responding to Mental Health Commission Inspectorate criticisms of 24-hour supervised mental healthcare residences, said the HSE was committed to reviewing the suitability of some high support hostel arrangements, having regard to the needs of the clients accommodated there.

Shock report on mental care suicides