Proper assessments might have alerted staff to the risks facing up to 13 people who went on to die by apparent suicide, the State’s watchdog for mental health services has found.
The Mental Health Commission's report follows concerns over deaths and governance issues in the Carlow/Kilkenny and South Tipperary area between January 2012 and March 2014.
The review found no evidence to suggest the death rate among patients was exceptional. But it found that adequate assessment of those at risk of suicide might have alerted clinical staff to the risk of a patient taking their own life.
In addition, training for risk assessment was insufficient, or else it was not being applied in all cases.
In a statement accompanying publication of the review, John Saunders, chairman of the Mental Health Commission, said a "fundamental cultural change" was required to ensure the mental health service puts the patient's needs first and provides a recovery-oriented service.
At the time of the review in March 2014, newly presenting 16- and 17-year-olds in south Tipperary were not receiving a safe, adequate service.
Concerns over the safety of services first coincided with the controversial reconfiguration of services in the local region.
This included the closure of a mental health unit in Clonmel, after which patients from Co Tipperary were referred to St Luke's Hospital in Kilkenny or the psychiatric unit of the Mid-Western Hospital in Ennis, Co Clare.
The move was opposed by a number of consultants and mental health staff at the time.
In its report, the review team found a lack of cohesion and “deep disharmony” between senior management and the medical consultants, which undermined clinical governance.
The team found “non-engagement” by some consultants in the region represented a serious and unacceptable risk to the service.
Understaffing and a heavy reliance on agency workers was another issue highlighted, as was poor communication by the service with patient, their families and carers.
Of the 13 deaths which formed part of the review, five occurred either in the department of psychiatry at St Luke’s Hospital, Co Kilkenny, or within 24 hours of discharge.
Four other deaths occurred while service users were under the care of a home-based treatment team; three died under the care of community mental health services; and one died while in a crisis support house.
In addition, there were four serious incidents including severe cases of self-harm, an assault on a member of the public by a patient and the deaths of a relative of a patient.
Concerns over a failure to remove of ligature points was also highlighted as an issue.
Ligature anchor points at St Luke’s were identified as contributing to the deaths of two residents in the previous 12 months..
