Dan Neville (Limerick West, Fine Gael)
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I thank the Leas-Cheann Comhairle for allowing me to raise the report into the death by suicide of Ms Anne Carroll on 17 October 2004 at Cork University Hospital. I wish to express my sympathy to the Carroll family in respect of this tragedy and the suffering it caused. Our objective is to ensure similar tragedies do not take place and that the recommendations contained in the report are introduced as a matter of urgency.

A report into the death of Anne Carroll was submitted to the Inspector of Mental Health Services on 18 November 2004 by Dr. Eamon Moloney, clinical director, south Lee mental health services. Ms Carroll had a history of mental health problems since the late 1970s and had been admitted on a number of occasions to inpatient psychiatric care. She was diagnosed as having bipolar defective disorder and, following an overdose of 200 tablets one week previously at home, was transferred to the GF unit from the intensive care unit at Cork University Hospital on 6 September 2004. However, on 17 October 2004 she returned early from her weekend leave to the GF unit and complained of feeling depressed. She had cut herself with a razor at home and it was reported by her family that she also tried to stab herself. However, there was no record of this on the hospital's clinical file.

When she returned to the GF unit, it emerged her bed had been given to another patient and there was some delay in finding a bed for her. During this delay in obtaining a bed she was noted to be anxious and stressed. Her family feel that Ms Carroll was extremely distressed by the delay and that this contributed to her suicide. They also stated they had expressed their concern to staff about her and requested that her clothes be taken from her. The family feels that insufficient support was offered by the staff of the GF unit to the family in the immediate aftermath of Anne's death and stated there was no suitable place to spend time with her remains.

The report into Ms Carroll's death outlines that the layout of the GF unit is unsuitable for the observation of patients. There is no high-observation or special care unit within the GF unit. A high-observation unit is an area within a psychiatric unit which provides a high level of observation while a patient is in an actually distressed state. There are no specified intermediate levels of observation apart from general observation and special observation within the GF unit. This means that in the absence of a high-observation area, the clinical staff is able to prescribe only special observation for patients requiring any observation level higher than that relating to general observation.

The alarm system was stated to be unsatisfactory and does not always work. It was stated the alarm system was not working on the day of Ms Carroll's death. It is a practice in the GF unit to admit patients to beds of other patients who have gone on leave for one or more nights and who have previously been on leave. The system does not allow for patients returning unexpectedly from leave because they become unwell. Ms Carroll returned early from leave as she had cut her wrist. Her bed had been taken by another person and there was considerable delay in obtaining a bed for her. Eventually another patient was discharged by the consultant on call and this provided Ms Carroll with a bed. The delay and uncertainty regarding whether she would obtain a bed appeared to have added to Ms Carroll's distress and agitation. The use of leave beds for newly appointed patients results in an unsafe situation if patients return early from leave due to deterioration in their mental status. There is no policy on leave beds and no audit had been carried out on the usage of beds.

There was no documentation in the clinical file on the death of Ms Carroll, apart from the entry on the pronouncement of death by the cardiac arrest team. There was no documentation of the interaction between Ms Carroll's family. which attended the GF unit following her death. The last nursing entry outlines Ms Carroll's return from leave to the GF unit. There was no documentation in the nursing file relating to her death. The final entry states that she returned from leave and settled for the remainder of the night. Due to this lack of documentation regarding the death of Miss Carroll and the immediate aftermath, the report found it difficult to draw a conclusion in respect of the support that her family received following the immediate aftermath of Ms Carroll's death.

I ask the Minister of State to implore the Health Service Executive and the Minister for Health and Children to respond to the concerns expressed in the report to which I refer and to ensure the necessary investment is put in place to correct the situation I have outlined. We must also ensure that further deaths do not take place in circumstances such as those to which I refer. Again, I offer my sincere sympathy to the members of Anne Carroll's family, who are extremely distressed about her death.

Tony Killeen (Clare, Fianna Fail)
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I am taking this matter on behalf of my colleague, the Minister for Health and Children, Deputy Harney. The case referred to by Deputy Neville is tragic and I wish to extend my sincere condolences to the family concerned.

In March 2005, the Minister of State at the Department of Health and Children with special responsibility for mental health, Deputy Tim O'Malley, requested the Mental Health Commission to prepare a report on the circumstances of the death of the named person. In November this year, the report was received in the Department.

The Mental Health Commission, which was established in April 2002, is an independent statutory body, the primary function of which is to promote and foster high standards and good practice in the delivery of mental health services and to ensure the interests of detained persons are protected. The report of the mental health services inspectorate of the commission examined the service provided in the acute psychiatric unit — the GF unit — at Cork University Hospital and the physical layout thereof. The report also examined the observation policies and procedures as well as bed usage and related matters. In preparing its report, the commission sought information from the Health Service Executive southern area on the actions undertaken by the health service since the death of the named person. The inspectorate also carried out a review of the circumstances surrounding the death. The inspection took place on 19 and 20 January 2006.

The GF unit at Cork University Hospital is the admission unit for the south Lee mental health services. It is a 46-bed acute psychiatric unit. There are 23 beds for male patients and 23 for female patients. I am informed by the HSE that it is engaged in a process to redesign the unit, which will include a high-observation area. A clinical audit committee has been established and staff have been provided with clinical risk management training.

Under the Health Act 2004, operational responsibility for the management and delivery of health and personal social services was assigned to the Health Service Executive. Accordingly, the Department of Health and Children has written to the HSE requesting that all shortcomings identified in the report be addressed as a matter of urgency. The Government adopted the report of the expert group on mental health policy in January 2006 and €26.2 million was made available this year to commence implementation. The latter amount includes €1.2 million made available to the HSE for suicide prevention initiatives. A further €25 million will be made available in 2007. The Government is committed to ensuring that the highest standard of patient care is provided within our mental health service in line with A Vision for Change.

As Deputies are aware, the report proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. It recommends a person-centred treatment approach which addresses each of these elements through an integrated care plan, reflecting best practice and, most importantly, evolved and agreed with both service users and their carers.