Prohibited transfers highlight breaches at mental health facilities

The issues came to light after the MHC published inspection reports over the weekend on St Ita’s Ward and Unit One at St Brigid’s Hospital in Ardee, Co Louth, at the APU at University Hospital in Ennis, and at St Edmundsbury Hospital in Lucan, Co Dublin.

The report found St Edmundsbury Hospital to be compliant with all regulations, rules, and codes of practice.

However, it found that the transfer of residents from the APU at University Hospital Ennis did not meet the transfer criteria as it was not in the best interest of the resident to be transferred.

It said in four transfer cases, there was no record of a medical review prior to transfer, and that the resident’s consent to transfer was not always documented.

The report said while all transfers were noted to occur after 9pm, one transfer actually took place at 1.20am.

It found that not all admission or discharge documentation was fully complete for all residents.

It said the toilets and shower rooms were not of an adequate standard and were in a poor state of repair — they had poor ventilation, unsuitable flooring, missing tiles, crumbling plasterwork and a poor standard of hygiene — and that no remedial works had taken place since the last inspection.

The high-observation area was in a poor state of repair and ligature points were a risk to residents’ safety and wellbeing.

A new bed management plan has now been drafted to address this patient transfer issue, and other plans are in place to address other issues.

The MHC report on 1930s-built St Ita’s Ward and Unit One at St Brigid’s Hospital, Ardee, said there were not enough accessible showers for the number of residents in Unit One. There were also insufficient clinical rooms and multidisciplinary rooms available.

It found an obvious blind spot in a seclusion room, which created a “notable concern” around the direct observation of a patient.

Medical administration records were found to be incomplete, with one record showing that a resident did not receive their medication on two occasions on the same day, and another showing that one resident did not receive their lunchtime medication on one occasion.

And while there was an extensive safety statement made available for Unit One, it did not fully address the health and safety needs of residents and visitors as outlined in the regulation, the MHC report said.

It did, however, highlight areas where the facility had made improvements, including the fact that each resident had an individual care plan. There was also evidence of excellent care being provided to dying residents, and there was a robust system in place for handling complaints, and the admission, transfer and discharge of residents were managed efficiently and effectively.