Dr. Austin O'Carroll:

The number of deaths seemed to rise significantly from 26 in 2019 to 47 in 2020. However, the number of homeless people has been increasing steadily since 2016. Looking at crude mortality rates, while the crude mortality rate had gone up since 2018 and 2019, in 2020 the crude mortality rate was actually lower than in 2016 and 2017. That means that the actual crude mortality rate was not significantly higher, taking into account rates over the last five years. The most likely explanation is that it is just simple statistical variation. However, looking at the crude mortality rate for long-term homelessness, it is clear that mortality rates really shoot up for people who have been homeless for more than 18 months. The mortality rate among people who have been homeless for more than 18 months is very high compared to that of other homeless people.

I also looked at the crude mortality rate of homeless people in private emergency accommodation versus those in supported temporary accommodation. The mortality rate of those in supported temporary accommodation is higher. That would be expected because the DRHE tends to put people who are sicker into supported temporary accommodation because there are better medical and social supports in supported temporary accommodation. However, we can see the mortality rate of those in private emergency accommodation is coming closer to that of supported temporary accommodation. That is important in terms of recommendations. It is also important because the population of people in private emergency accommodation has been rising significantly and is coming closer to the number of people in supported temporary accommodation. That is important in terms of recommendations because private emergency accommodation has less health and social supports.

The crude mortality rate in log-term accommodation is much higher, as you would expect, because the people such accommodation are older and sicker. Long-term accommodation is like nursing homes, and the mortality rate is significantly higher.

There were three rough sleeper deaths in 2020, one in 2019, one in 2018, zero in 2017 and two in 2016. That does not represent a huge variation, particularly as we know that there has been an increase in the numbers of homeless people.

We looked at median age. Median age is the middle age. For example, if three people died, aged 42, 47 and 49, respectively, the median age would be 47. The median represents the person in the middle. It is important to recognise that the median age depends on the population. For example, the median age of death in a nursing home will be much higher than the median age of death in a secondary school.

The median age for homelessness has not varied that significantly and was not much higher in 2020 than in previous years.

As for the location of death, eight people died outdoors. Of those, seven were single people experiencing homelessness. Four had been sleeping in their own accommodation. They had had emergency accommodation for a few months prior to their deaths and had been sleeping in that accommodation the night prior to their deaths, so they were literally out one night when they died. Three people had been rough sleeping regularly.

One of the big things to point out is that the main determinants of early death in people experiencing homelessness are structural causes related to poverty causing a lower life expectancy. Poverty is also associated with drug addiction, which is one of the main determinants of death. We know this both in Ireland and internationally. It is probably the main determinant of early death due to overdose and spread of blood-borne viral infections as well as other causes. Therefore, poverty and its effects, namely addiction and increased illness, including increased mental health illness, are the main causes of early death.

The main recommendations of the report are that if we want to learn from deaths, we need first to gather information. We should gather information like this on deaths every three to five years because that allows us to look at and see trends in death. Very importantly, however, you learn a lot more from a single death sometimes than from looking at all the deaths. You might look at the case of a person who died, find out where they died, find that they died outside, find out what services they had been in touch with, find that they had been in touch with a hospital, a drug addiction service or homelessness services and find out what happened, when they linked in with those services and whether anything could have been done to prevent what happened to them eventually. For example, two people died from overdoses last December in the Phoenix Park. We chased that up. We found they had been on methadone but had stopped attending appointments the previous month. We have now tried to get people who default from methadone treatment back into services. We have taken action. Often you learn from looking at single deaths, as part of what we call critical case analysis. This needs to be done in a non-blame environment.

We also need to reduce long-term homelessness, and the Housing First model is the best way to achieve that. We should have a multi-agency committee to review five-year mortality rates. We should ensure there is access to primary care in private emergency accommodations. We need to improve access to mental health treatment, particularly for those with dual diagnosis, that is, people who have coexisting drug addiction and mental illness. We know of interventions to help to reduce overdose fatalities, including improved access to naloxone, supervised injecting centres and access to opioid substitution therapy. We need a protocol for overdose risk assessments and need to develop protocols for review of non-fatal overdoses.

Lastly, we know there are interventions to help to improve mental health that we need to implement. Overall, we need to address social inequality, stop people from becoming homeless, address housing issues, support Housing First to reduce long-term homelessness, address overdose suicidality and have a learning system to improve the quality and safety of services.