High Court conducts inquiry into provision of psychiatric services in secure care unit

A High Court judge held an inquiry into the provision of psychiatric services in a secure care unit and units in general. This had come about because a child in the unit had written a letter to the judge and the judge had taken the letter as a letter of complaint.

Further to this, the guardian ad litem (GAL) for the child had raised an issue regarding the adequacy of provision of psychiatric services. Senior counsel for the GAL had remarked that the justification for civil detention was that it was therapeutic and therefore appropriate psychiatric facilities should be available. Furthermore, the psychiatrist attending the unit on a monthly basis had raised concerns in an email to his line manager regarding the robustness of the services. The judge had decided to hold an inquiry into the matter.

When the case returned a few weeks later, senior counsel for the CFA gave a synopsis of the provision of psychiatric services to secure care units. He said that TUSLA did not employ child and adolescent psychiatrists, that provision remained with the HSE. He explained that children in special care were in receipt of services pursuant to the provision of the Health Act, which was within the statutory jurisdiction of the HSE. However services such as counselling, therapeutic input and speech and language were provided by the CFA under statutory remit.

In relation to an emergency, in common with any other citizen of the state, the children in secure care could avail of the accident and emergency admissions process by presenting at casualty. There the psychiatric registrar on duty would carry out an assessment under the framework of the Mental Health Act 2001.

Senior counsel for the CFA went on to say that secure care was not a detention centre under the Mental Health Act 2001, but there were children on the list who might require psychiatric care. He said the court was entitled to know if a child required assessment, if it had been done and arising out of that if it was necessary for the child to engage with services. If the child required the engagement was it sufficient that it was done in collaboration with other services? “If there is a feature in the child which requires psychiatric provision, what are the clinical provisions, what is the likelihood of provision?”

“There has to be an appropriate therapeutic rationale for the detention of children for therapeutic purposes, absent that it is unlawful,” remarked the senior counsel for the GAL. The entitlement of the judge to make the order to detain the child was predicated on the existence of that therapeutic rationale.

The clinical director [a doctor] of the HSE Child and Adolescent Mental Health Services (CAMHS) was asked by the HSE to give evidence regarding the psychiatric services being provided to young people being detained in secure care centres. The doctor explained to the court that secure care was separate to care within an approved centre where a young person was an in-patient.

The Mental health Act 2001 Register of Approved Centres for child and adolescent services included six units, which he named. Within those units young people were seen within a set period of time following admission and under in-patient care of a consultant psychiatrist. There were clear regulations around this.

The doctor had been a member of the Mental Health Commission previously for five years, he explained to the court that a mental health illness was defined under the Act and the grounds must be the same for a mental illness for a child as would be the case for an adult. The barrister for the HSE asked the doctor to explain to the court what access young people in secure care had to psychiatric services.

He explained that in the short term, the young people in secure care may be involved in a service in the community. Their particular needs would be looked at and a range of support services was available such as the Assessment Consultation Therapy Service (ACTS), clinical resource and multidisciplinary services within ACTS. Care planning would be provided for their identified mental health needs and this was done on a consultation basis.

[Assessment Consultation Therapy Service (ACTS) is a small national specialised clinical service that provides multidisciplinary consultation, assessment and focused interventions to young people who have high risk behaviours associated with complex clinical needs.  ACTS also supports other professionals in their ongoing work with young people and their families. See www. http://tusla.ie/services/alternative-care/assessment-consultation-therapy-service-acts/]

These dedicated consultation sessions were linked with secure care settings and were part of a range of services such young people needed access to.

An issue had arisen a few weeks previously during the Minors’ List regarding an email one such consultant had written to his manager regarding concerns around his specific role and function within a secure care unit and the responsibility attached to the role.

In relation to that email, the Director of CAMHS told the court that the consultant who was in a locum position had been seeking clarification around his role in dealing with a very complex system. Within that particular secure care unit the young people had access to emergency services and the 24 hour on-call psychiatric service in the University Hospital as well as certain access to the locum consultant. Currently a 24 out-of-hours child psychiatric service was not available throughout the country, said the director. “It should be but isn’t at this time.”

Senior counsel for the GAL quoted an excerpt from the locum’s email which read: “The young people with the most complex difficulties receive less than the treatment needed as standard.” The locum (Doctor Y) wanted a proper multidisciplinary service linked up to the psychiatric consultant for the children in secure care, said counsel for the GAL. “Clearly the situation with regard to CAMHS cover is not satisfactory, [the locum] felt he was overstepping the boundary from a consultative to intervention based role.”

He continued to read out excerpts from the letter. The doctor had written that he was based in another county and could not respond to urgent requests and that intervention was often required. For example it could be an ADHD query, a cognitive disorder with violence, a mix of low mood anxiety cases or an emerging personality disorder. There was a need in some cases for medication to be prescribed when he attended. He felt that a local CAMHS team was needed that would be more responsive to the young people in the unit and that “a clear and equitable referral pathway” was required.

Counsel for the GAL pointed out that the court was detaining young people in secure care for treatment, for therapeutic intervention and one aspect of that may be psychiatric, therefore “it was perfectly reasonable that the court would enquire to see if the very basis of its order is getting the intervention to see if the detention is legal. The problem is the man providing the service is saying he’s not satisfied that he is providing the service.

“What really is necessary is that the man who wrote the email should come to court,” concluded counsel for the GAL. “It is a matter of sufficient seriousness that the person who is providing those therapeutic services is saying they are inadequate.” He quoted again from the letter: “’The young people with the most complex difficulties receive less than the treatment needed as standard.’”

The judge decided to bring the doctor into court as solutions to difficulties might arise. The barrister for the HSE pointed out that “the benefit and therapeutic rationale of these places encompasses many different services, so the entire therapeutic benefit isn’t just around the psychiatric services”.

The judge said that although a settling in period was needed for a child after admission to secure care before therapies began she was not happy to commit a child to be detained “if there’s going to be a massive lag in time for therapies kicking in”. She wanted to see a plan at the point of entry of a child and did not want to see them under-occupied and under-stimulated. She wanted to see a service out there that was called upon when appropriate, the system “could be far more sharp and constructive to the needs of particular children,” the judge commented.

She said that she wanted to a tightening up of provision of services. “These children have suffered so much, this should be a lucky break to make up for everything else, it should be about the quality of what they’re getting. How can the system be smartened up to do the very best for these children?”

The following week Doctor Y, the consultant psychiatric locum for the secure care unit, attended court.

The doctor, who worked in an adolescent in-patient Approved Centre in another county told the court that he visited the secure care unit about once a month and could be flexible on that, but could not attend in an emergency due to distance. He had been contacted recently by management at the unit to attend due to a situation involving violence and aggression but had not been able to attend until the next day.

His contract with the HSE did not specifically deal with the secure care unit. The doctor had done his training there with his predecessor and had attended on and off for a few years. Although this work had been in his predecessor’s contract, it was not in his one and he had chosen to take it on.

Senior counsel for the HSE told the court that it was proving extremely difficult to recruit a consultant psychiatrist for the county where the secure care unit was located. The funding was in place if a person could be found.

“There is a national shortage of child psychiatrists,” the consultant told the court. He himself had to travel to Mayo and Waterford due to the shortage. The judge said she was at a loss going forward.

TUSLA managers had informed the doctor that in other secure care settings psychiatrists were paid to spend more time than he was and had different contractual arrangements.

The doctor explained that “throughout the years there really hadn’t been any issues with psychiatric illness in [the unit] but the recent severity of [one child’s] behavioural difficulties necessitated I do something, so now I had intervened to make a difference. In reality most CAMHS services would not offer young people like the ones [in this unit] psychiatric intervention as most of them do not have a psychiatric illness.”

There had been a shift in the last few months from a consultative role to an intervention one and that was not what he had chosen to take on. He had written the email to his line manager to alert her to the fact that there were limitations that he found himself under and that he felt he had overstepped the mark in intervention and had gone beyond consultancy. He did not have access to a CAMHS multidisciplinary team, or a cohort of social workers and psychologists. The unit did not have a dietician or occupational therapist and he could not bring his dietician with him from his in-patient unit so that service had to be hired privately. What he was asking for was for the “gaps to be filled locally”.

Other issues were problematic. For example the secure care unit did not have a medication dispensation policy, it was currently being drafted. There was a reluctance coming from TUSLA in giving young people medication for behavioural difficulties. This resulted in adjustment delays of medication levels, which was wrong in his view. In the unit there could be a delay of a month in the adjustment process so he had brought the local GP into the mix and they contacted each other frequently.

He did not know who had clinical responsibility for the psychiatric care of the young people in the secure care unit.

Although the doctor agreed with senior counsel for the GAL that the residents there required access to a full multidisciplinary CAMHS service, he told the court they were excluded from that by virtue of absence of a psychiatric illness. While they did get access to a multidisciplinary (MTD) service from the ACTS team he needed easy access to a MTD service to have the support of peers in the provision of service. Rather than his attendance on a consultative basis, the ideal would be for the residents in the unit to receive their service locally but that option was not available, said the doctor.

The secure care unit was not set up to deal with the outbursts of aggression of these young people, he said, and that was a big factor. Their violent and aggressive behaviour was a common feature of this cohort of young people. He was not available to attend the unit after hours. An emergency service would be provided for by an A&E department. “I’m not sure it is terribly helpful, it is hard to contain a young person who is violent without sedating them. Sending them to a hospital setting may not be the answer,” he told the court.

The judge decided that a formulation of a healthcare policy was needed for the secure care unit. Senior counsel for the GAL said he believed that the appropriate response was that the CFA should bring a document or plan to the court which set out the psychiatric services in each unit to satisfy the court those services were available.

“If they are not addressed people will have to come into you and say that when there is an application for detention that it should not be made because the constitutional rights of the child will not be satisfied,” he concluded.

The judge said a policy would have to be formulated on the understanding that some children entering secure care would have to be treated if a psychiatric illness was identified. The screening for that illness should take place within a few days by a psychologist or psychiatrist.

At the moment it was a very ad hoc system so the plan for this particular secure care unit should become policy. “What is available to [the unit]? Is it sufficient in terms of screening psychiatric illness or is it behavioural and that would normally fall to a psychologist? What are the deficiencies in terms of what [Doctor Y] has identified in [the unit] to meet the constitutional rights of the standard of care they should get in secure care? There isn’t a plan and there should be one,” the judge said.

The judge asked for the plan to be circulated within a month. The model could then be looked at by other units.

See case histories 2015, Volume 4, No.3 for previous report on the issue.