A judge in the High Court refused to place a disturbed child in a secure care unit until she had heard further evidence about the provision of psychiatric services to the children there.
The manager of the three bed secure care/special care unit for 11-17 year olds attended the High Court in order to give evidence about the psychiatric care available to the children.
The senior counsel for the CFA told the parties that the judge had wanted a better picture of this particular secure care unit before placing another child there and that was why the manager had been brought in to give evidence. This had come about because a child in the unit had written a letter to the judge [the judge remarked that she had taken it as a letter of complaint].
Further to that the guardian ad litem (GAL) for the child had raised an issue regarding the adequacy of provision of psychiatric services.
The manager told the court that the secure care unit worked with the families and the guardians ad litem of the children. Each child was allocated two key workers and there was an individual care programme. There was a special educational provision on the grounds of the unit with an individual educational plan for each child.
Ancillary services such as speech and language therapy, psychological services and addiction counselling were provided by ACTS services under Tusla. (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. See www.tusla.ie)
The unit was subject to statutory inspection by HIQA. Yearly reports had been published since 2012 which had overall been very positive.
There were two children currently within the unit as one child had recently been transferred to another facility. The manager told the court that she was satisfied that the level of service provided to the children was appropriate and if a further admission was sought the therapeutic needs of that child would be met.
The children who came to the unit were at the extreme end of harm and self-harm was a feature. They had had gross exposure to sexual abuse and violence, family rejection and emotional abuse.
There was a vacancy for a child and adolescent psychiatrist in the county area, however it had not be taken up and therefore as an interim measure the unit was using the services of a consultant from the nearest city. An inter-agency meeting was taking place in the first week of December in relation to services.
Senior counsel for the guardian ad litem of the child (A) who had written to the judge asked if anybody involved in the provision of the psychiatric services had raised an issue as to their adequacy. The manager replied that the psychiatrist himself had raised an issue about his provision of service in terms of location. He had done so in correspondence, however she had not seen the correspondence and did not know when the issue had been raised.
Senior counsel for the GAL told the court that he wanted “an account of these concerns, the nature of those concerns, when they arose and how they have been addressed. I am trying to establish the factual position.” He continued: “Concerns have been raised as to the adequacy of psychiatric services in [the secure care unit].
“They have been raised by the person providing them, you are not sure when or how, you are not sure at what administrative level those concerns are being dealt with or what steps are being taken to ameliorate them. Has the service changed at all since [the psychiatrist] raised those concerns?”
“The current provision is adequate,” replied the manager of the unit.
The court was told that the psychiatrist providing treating services to the unit by visiting once a month was currently on holidays until early December. The judge wanted to know how an emergency psychiatric situation would be dealt with within the unit until his return.
It would be provided for under CAMHS (child and adolescent mental health services), said the manager, and they could provide a psychiatric risk assessment.
“If you have a situation where a child is self-harming by trying to ingest a piece of glass, what facilities do you have to deal with that?” asked the GAL senior counsel.
“We would first ring [the local hospital GP on call], they would give medical advice.
Generally speaking we would send a child to A&E in hospital, they would be met there by the psychiatrist on call, who would give us advice for possible referral to local CAMHS the next morning or afternoon,” replied the manager.
The GAL’s senior counsel pointed out that the unit’s recourse was to ring the local doctor and that the secure care unit had no facility to ring a psychiatrist directly. The cohort of the children who attended the unit were disturbed and generically as a group linked to psychiatric issues, yet their recourse in an out-of-hours emergency was to ring the local doctor.
He pointed out that mental health issues do not follow the clock and some significant events had happened within the unit recently, out-of-hours. The GAL’s senior counsel questioned if it was safe to have the children there in those circumstances. He told the court that concerns had been raised for some time about the adequacy of psychiatric services within the unit and in order for the court to detain people in it, the detention had to be therapeutic. Psychiatric services were an important part of that therapy, said the senior counsel.
The manager told the court that in the last three years the cohort admitted had required full access to psychiatric services.
Then the GAL’s senior counsel pointed out that the cohort “for the last little while had been extremely demanding and at the extreme end of the spectrum. It is less than satisfactory detaining young people in a unit where the person providing the services himself says they’re inadequate.”
“They need to be improved,” replied the manager. “The provision in place with [the psychiatrist] is adequate but a more robust service moving forward is more ideal.” Under the circumstances where that doctor himself had raised concerns about the adequacy of the psychiatric service being provided to the secure care unit, the GAL senior counsel told the court that he would have to then ask if it was appropriate to send minors there at all.
He felt the judge needed to hear evidence from the treating psychiatrist as soon as possible.
Evidence was required regarding how long the concerns had been there, how many people were involved in those concerns at an administrative level and how the concerns were or were not dealt with. Furthermore, all the documentation relating to the concern raised by the treating psychiatrist needed to be seen by the court.
Currently, there was a question mark as to whether the court could be satisfied that a child detained in that secure care unit would get appropriate therapeutic input. He said that civil detention was a very unusual order and it included decisions regarding medical treatment.
The justification for civil detention was that it was therapeutic and therefore there should be appropriate psychiatric facilities.
The judge replied that she wanted the third place taken up in the unit but that she felt constrained by what she had heard that morning. She said that by the end of the day she would like such assurances as would enable her to give a secure care bed to a child who badly needed it, but only under strict and certain assurances would she do that.
The manager for the unit then told the court that the system with the treating psychiatrist had been put in place before.
The judge said that an inquiry would have to be held into the matter. She wanted to see all documentation relating to the psychiatrist’s concerns and witnesses would have to be called. Until then she could not give the third bed to another child.
“If I can free up a bed for someone who needs a bed I will do it. With great caution I will release children into step down places to keep children in beds who need to be there, but I won’t do it if I have doubts of the system and until that it allayed I will not use the bed that is there,” the judge remarked.
She said that the system within the secure care unit of therapeutic treatment needed to be looked at and that not enough information was being given to the court.
“I want a timetable from now on, when are the various therapists going to see the child?
The children seem to be in these places for weeks on end and nothing much happens. I also have the impression they are bored to tears, there is no real system of education to keep them focused, occupied, despite their problems,” concluded the judge.