Dan Neville (Limerick West, Fine Gael)

I am thankful to have the opportunity to raise the report of the committee of inquiry to review care and treatment practices in St. Michael's unit, South Tipperary General Hospital, Clonmel and St. Luke's Hospital, Clonmel included in the quality and planning of care and the use of restraint and seclusion, and to report to the Mental Health Commission. I will deal with one small but important area of the comprehensive and detailed report.

The clinical risk manager reviewed fractures recorded in St Luke's Hospital, Clonmel from July 2002 to 31 January 2004. The regional risk manager calculated that, at the time of the September 2004 report, the risk of residents of St. Luke's Hospital or St. Michael's unit sustaining a fracture was between two and three times higher than the average risk of residents of the other psychiatric hospitals in the region.

The fractures in Clonmel were of small bones in hands and feet and fractures to the upper end of the humerus differed from the number and type of fractures seen in the other units where fractures of the hip and wrist are as a result of falls from bed and falls on an outstretched hand. The report referred to the fact that most patients are cared for in wards which are permanently locked and where there is restriction of movement. A number of patients are elderly frail and vulnerable. The report stated:

There is a lack of rationale for combining patients with different diagnoses i.e. patients with challenging behaviour and frail patients. The resulting patient mix means that some patients are at risk of injury from other patients.

It is a cause of concern that this review highlighted many other incidents of fractures occurring in these specific patients in the past. In some situations, old fractures or healing fractures were identified coincidently on X-ray. The report went on to state that a worrying observation made during the course of this review was that in 18 of the 19 incidents involving fractures the documentation states that they were not witnessed. In the remaining one, it is unclear whether there were any witnesses. Two of the 19 residents each had fractures on two occasions during the 18 month period and five of the residents suffered earlier fractures.

A retrospective examination of the charts of the patients of St. Luke's Hospital showed that in many cases there was no documented supporting history of injury, trauma or signs or symptoms to account for the previously undiagnosed fractures. On 15 July 2005, a meeting of senior managers and clinicians was held to consider the report. The meeting was not minuted. Many of those attending were unclear about the authority of the meeting. At the meeting the regional risk manager outlined the findings of the report and indicated that there was a strong possibility of non-accidental injury. The possibility of informing the Garda was considered. The need for further investigation into the causes of the injuries and the very high proportion of unobserved injuries was discussed and generally agreed. However the matter was not reported to the Garda and no effective action was taken on foot of the risk manager's report.

No minutes of the meeting were kept or circulated and no follow-up meeting was arranged. Those attending the meeting expected it would lead to the development of an action plan for the implementation of the recommendations of the report but discussion about how this would be achieved, whether through further investigation or a review of clinical and organisational practice, was not concluded.

The Mental Health Commission inquiry report makes the following observations in regard to the investigation into the fractures: "Taking into account the lack of further investigation following the September 2004 report, the limited implementation of its recommendations and the extreme slowness of the process, the inquiry team considers that the safety and welfare of residents was not given the highest priority." The inquiry team believes that, where the safety and welfare of residents appears to be at risk, prompt action is required. Further investigation to clarify the level of risk and implementation of measures aimed at reducing the risk is necessary. The inquiry team believes that the lack of urgency of the process following the September 2004 report, the lack of further investigation to clarify the level of risk to residents and the failure to implement many of the report's recommendations indicate that the safety and welfare of residents was not given the highest priority. The inquiry team believes that this was probably influenced by industrial relations problems, a concern to avoid bad publicity and potential for distress.

Patients and their families should feel safe and when one considers that only one of the 19 injuries uncovered in September 2004 was witnessed by the staff, it is of great concern. The failure to refer the matter to the Garda following consideration smacks of a cover up. The risk of sustaining a fracture in St. Luke's hospital was between two and three times higher than that of the local psychiatric hospital which highlights the seriousness of the level of injury. The welfare of the patients continues to be of concern and will only be satisfied by the closure of the hospital and the transfer of patients to modern hospital conditions.

This hospital was recommended for closure because of the conditions. I have only referred to a section of the report, which contains details of the conditions which prevail but we do not have time to go further into the detail today. If these conditions applied to any other group of patients, there would be a three hour debate in the Dáil on the matter.

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