Protocol on special care processes approved in High Court

Five months after the High Court conducted an inquiry into psychiatric services for children in secure care senior counsel for the CFA produced a protocol on Special Care Processes (SPC) as produced by both the CFA and HSE.

The forward for the protocol acknowledged that it had been developed at the request of Judge O’Hanlon in order to ensure that Special Care Order applications “made to the court clearly communicate the therapeutic approach the Child and Family Agency and HSE will adopt to address the issues underpinning those applications.”

It stated that the process document (the protocol) and the operation of the joint system of care provided by the HSE and CFA would be subject to ongoing audit/governance. This system of care would provide for the mental health needs of young people placed in Special Care Units.

The document defines Special Care as a “welfare-based Social Care intervention though placements are intensively supported with on-site education, vocational training, therapeutic supports and detailed Programmes of Care aimed at supporting resident young people’s timely return to the Agency’s community based Centres, Foster Care or home as soon as this can be achieved.

“Tusla’s policy on the use of Special Care is a short-term, stabilising intervention that delivers safe therapeutic care in a secure environment and that the restriction of a young person’s liberty will always be limited to the shortest possible time. Accordingly, all placements in Special Care are intended for an initial period of three months only.”

Senior Counsel for the CFA told the court that the Department of Children and Youth Affairs had communicated to them the morning of the 9th of June that they had approved funding to engage and recruit a consultant child and adolescent psychiatrist for three days a week, that is, 0.6 of a consultant.

The judge remarked that this was “an exceptionally good move, it’s a monumental move and it’s appreciated”.

However she then noted that “these cases are too serious, the court will require the assurance that the therapeutic services are delivered. The commitment is there, now it is about realising it in a credible period of time to get that service in place.”

Senior counsel for the GAL regarding the case [involving a child, Q] that had brought about this Special Care Processes document remarked “that now the court should be in a much better position just to judge what is actually happening, the social work report doesn’t give a proper feel of what is actually happening.

“It should leave the court and all the people involved in this process in a much better position to know what is going on and it should cut down on time in court, it may not be more than very good, Judge, but everything seems to be in hand.”

He then pointed out that within the protocol it seemed to be envisaged that if the young person in secure care had had a previous involvement with CAMHS that it would still be responsible for their psychiatric care. In practice that would bring about a situation where a child may be geographically well separated from the CAMHS unit, which would create problems.

The person about to be recruited should be the person with clinical responsibility for psychiatric care for the child. The protocol could only work when the new psychiatrist was recruited, he remarked.

The following week Judge O’Hanlon delivered a lengthy judgment concerning a review of special care in the case of the minor [Q], a young person with no less than 23 residential placements. She had also spent time in Special Care in each residential unit in the State and presented “at this stage as a child in deep distress” wrote the judge.

The judge addressed a number of issues within her judgement which included the systemic issues around special care as highlighted by the Q case and the court’s responses to those issues. It also addressed the possibility of an agreed protocol between the HSE and CFA “to alleviate the lacunae in care provision which arises through the historical development of the two parallel services.”

The judge wrote: “It is the strong view of this Court that the problems of this young person, while not neatly fitting into the category of a detainable illness under the Mental Health Act 2001, was clearly one where psychiatric intervention, assistance and assessment were of vital importance. It is of concern that this Court had to make several orders before any proper psychiatric assessment occurred. The assistance of the child and adolescent psychiatrists would have greatly benefited this young person at an earlier stage and would have better informed those providing her with services and making decisions about her care.”

She also wrote: “In order to resolve the systemic issues around special care as highlighted by this case, this Court both welcomes and accepts the efforts made by Mr O’Brien which have resulted in the Department of Children and Youth Affairs having communicated as recently as the 9th June, 2016 that they are willing to recruit and put in place 0.6 of a consultant child and adolescent psychiatrist. This would be the equivalent of three days a week in terms of a working consultant psychiatrist, who will be recruited to attend each of the three special care units in this country once a week in order to alleviate one major systemic difficulty.

“That difficulty was that the CAMHS (Child and Adolescent Mental Health Service) was limited to children with a mental health disorder as defined by the mental health legislation and CAMHS is a service run by the Health Service Executive.  ACTS (Assessment, Consultation and Therapy Service), on the other hand, is a service run by the Child and Family Agency and, to date, ACTS has not had the assistance of a child and adolescent psychiatrist within its remit.  This left a risk that there would be a lacuna in terms of the provision of psychiatric services as identified by Dr Keith Holmes.”

The judge accepted the joint proposal of the CFA and HSE to appoint 0.6 of a working consultant psychiatrist. She understood that there was a designated child and adolescent psychiatrist for the time being with Ballydowd Special Care Unit and that another psychiatrist had agreed to continue his role in respect of Gleann Alainn Special Care Unit. The Court was awaiting confirmation that the designated psychiatrist for Coovagh House Special Care Unit would continue there for the time being also.

In her judgement she noted that the Court could not detain a child under its inherent jurisdiction if the therapeutic rationale was undermined by a lack of resources.

The Court now expected that certain basic documents “shall be provided to the Court” on the first ex parte application to place a child in special care under the inherent jurisdiction of the High Court. These documents would be known as the “Programme of Special Care”.

“The following are the six documents which will be compiled and provided:

  • The first document shall be a care plan provided by a nominated social worker.
  • The second document shall be a placement plan provided by a named person within the special care unit.
  • The third document shall be a placement support plan also provided by a named person within the special care unit.
  • An individual education plan shall be produced and shall be signed off by a designated person from the special care school concerned.
  • The fifth document will be an individual therapeutic plan and shall be provided by a named person from the ACTS team.
  • The sixth document will be a psychiatric treatment / intervention plan and, under the interim protocol, be provided by the relevant HSE consultant psychiatrist. This element of the Programme of Special Care will only be provided where treatment and intervention are deemed necessary as per the third strand of the “O’Brien Principles”.”

The protocol itself outlines the responsibilities of the Assessment, Consultation and Therapy Service (ACTS), the responsibilities of the HSE and Adolescent Mental Health Services (CAMHS), the Consultant Psychiatrist Input and Responsibilities, the Special Care School responsibilities, the role of the Special Care Court Liaison, the responsibilities of Special Care, and the multidisciplinary responsibilities regarding the Social Workers.

The protocol also states that all interventions in Special Care will be underpinned by a Programme of Special Care (PSC) which would include the planning documents referred to above. It detailed who will provide those plans and who the documents will be shared with.

Ms Justice O’Hanlon noted in her judgment that although the adoption of the protocol would involve an increase in paperwork, it was hoped that the extensive documentation would provide clarity and reduce the time spent in court.