Maire Devine (Sinn Fein)
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I welcome the Minister of State at the Department of Health, Deputy Helen McEntee. It is good to have the correct Minister of State in the House. It is not the case that Senator Pádraig Mac Lochlainn was shooting the messenger because this issue affects all Senators.

The issue I raise is the care of children outside the State. A small number of children need special care which cannot be provided here and are sent abroad to avail of a broader range of treatment options, supports and interventions. In the past two years six children were sent abroad for this reason. However, records are not held for other years. Data must be collected nationally for future reference and use. Of the six children sent abroad, three were sent to the St. Andrew's facility in Northampton in England. I do not know where the other three were sent, but perhaps the Minister of State might provide that information. The lack of facilities for children who require them means that some children are sent abroad where they do not have access to family, friends and someone who will fight their corner. These disturbed and vulnerable children do not have a voice abroad and are in a dire position. The cost of placing three children in facilities abroad for one year is €1 million.

A few weeks ago Channel 4 broadcast a "Dispatches" documentary, "Under Lock and Key", which painted a damning picture of disgraceful conditions at the St. Andrew's facility. It found that children were held in an institution that did not meet their needs, make them better or keep them safe. The facility is operated by one of the largest and wealthiest health care charities in Britain. Serious concerns arising from the "Dispatches" programme include that patients were subject to restraint, seclusion and frequent sedation. An inspection by the Quality Care Commission, the British equivalent of the Health Information and Quality Authority in this jurisdiction, noted the use of a technique known as prone restraint. This face-down method of restraining a person, with which I am familiar, is widely used across all wards in the St. Andrew's facility which caters for young children aged between 11 and 18 years. The use of prone restraint has been banned here because it compromises respiratory function and has caused deaths in the past. If someone sits on a person and restrains him or her in a prone position, it cuts off his or her airways.

In a six-month period between 2015 and 2016 prone restraint was used 600 times in child and adolescent wards. One 15 year old patient remained mainly in segregation for 22 months in a room with very little natural daylight.Four patients died within seven months of each other in one ward between October 2010 and May 2010. All of those patients had been prescribed the drug clozapine, which has been lauded as the new wonder drug for schizophrenia in particular, but it is also what we consider quite a dirty drug, having too many side effects and needing constant monitoring.

It is a damning report of a health-care facility to which we send some of our most vulnerable and disturbed children. What is our oversight? Tusla claimed that St. Andrew's was highly regulated. Do we have any input or impact there? Do we carry out cross-balance checks to ensure our children are safe over there when they are all alone?

Helen McEntee (Meath East, Fine Gael)
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I thank the Senator for raising this extremely important issue. I know a programme such as the "Dispatches" programme can be very upsetting, particularly for someone with a child with a mental health problem or disability, and even more so for a parent whose child is there. As the Senator said, three young people with mental health problems have been sent over there. I am sure people in Tusla and the disability sector are speaking to the HSE officials who, I know, are over and back quite frequently. They were over in October before the new facility was occupied. They have been over since then and have assured me they have not found any issues with the three young people currently over there. However, it is extremely important we are not complacent and that we ensure the checks and balances we have are up to the highest standard possible.

The HSE is committed to ensuring that all aspects of mental health services are delivered in a consistent and timely fashion. However, on occasion as we know, the presenting clinical need of children is such that current service provision is not in place to address identified need here in Ireland.

Child and adolescent mental health services fall within the secondary and tertiary levels of care provision, based on the increasing severity of the mental health need. Tertiary services provide specialist mental health services for those children and adolescents who have complex and severe mental health problems or who are at high risk of harm. It also includes those with an eating disorder.

The four HSE CAMHS units operate as a national network of inpatient care. Each has a regional remit and co-operates with other units to ensure optimal utilisation of available bed resources. I know we have a difficulty in recruiting staff at the moment which, of course, has a knock-on effect on the ability to use all our beds. We are trying to deal with that.

There is a small group with particularly complex needs who may require a level of specialised intervention not available in Ireland. In such cases, a child or young person may be placed in out-of-State care at a facility abroad, which offers a wider range of treatment options or interventions than those provided in Irish facilities. In such cases, priority is always given to the care of the young person's needs, and placements are made in the best interests of the child.

The HSE operates a treatment abroad scheme for people entitled to treatment, along with associated costs, in another EU state. The scheme is governed by EU regulation, and in accordance with Department of Health guidelines.

The scheme allows a consultant, based in Ireland, to refer a patient normally resident in Ireland for treatment in another EU member state or Switzerland, where the treatment in question meets various relevant criteria as follows. Following clinical assessment, medical evidence must be provided by the referring hospital consultant, giving details of the patient's medical condition, the type of treatment envisaged and the proposed provider of the treatment abroad. The referring consultant, having reviewed the patient in the immediate previous two weeks, must certify that they recommend treatment in another EU or EEA country. The treatment must be medically necessary and meet the patient's needs. The treatment must be a proven form of medical treatment and not be experimental or test treatment. Care must be in a recognised hospital or other institution and under the control of a registered medical practitioner. The treatment must not be available in Ireland or otherwise not available within the timeframe normally necessary for obtaining it in Ireland, taking account of the young person's current state of health and the probable course of the medical condition.

The HSE keeps the needs of young people with mental health issues of greater severity under review, where the treatment abroad is considered necessary and in the young person's interests.

The process of finalising the design brief for the national paediatric hospital is near completion. This will include a 20-bed CAMHS inpatient unit, incorporating an eight-bed specialist eating disorder service. We know the reason that many of our young people are sent abroad is to deal with eating disorders. The provision of a ten-bed adolescent secure unit is part of the planned redevelopment of the national forensic services at Portrane. We hope the contracts will be signed in coming weeks so that we can get moving on that. Such additional service initiatives should assist in providing services not currently available.

Children with difficult life experiences and mental health difficulties require the highest possible standard of multi-agency supports to address specific needs. The HSE is committed to working to ensure this is attained. It is also committed to ensuring that those children who are on the island of Ireland receive the same level of care as those here.

Denis O'Donovan (Fianna Fail)
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That was a very thorough response.

Maire Devine (Sinn Fein)
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I thank the Minister of State for her response. She has outlined the process and criteria for the treatment abroad scheme. However, my concern is with the oversight of the care of those children and the facilities in which they are being treated as opposed to the rigmarole of getting them such treatment. It is about where we are sending them to. This report was damning of St. Andrew's and we cannot stand over that.

The Minister of State said HSE officials carried out a visit. Did they do so on the back of this report or was it prior to the report? How often do they visit? Patients in voluntary and mental health facilities have a mandatory six-month review involving all concerned - case workers, health-care workers and family - to ensure the patient's needs are being met. I do not know how they are being met in a very unsuitable and scary environment for children.

Denis O'Donovan (Fianna Fail)
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If the Minister of State has the answer, I am sure she will respond to it.

Helen McEntee (Meath East, Fine Gael)
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It has been brought to my attention that many of the cases shown in the programme were historical cases and since then HSE officials have made regular visits to the children sent over there. As I said, there were visits in October before the new facility was occupied and there have been visits since then.

Those high-intensity cases or the ones with most specific needs are kept under regular scrutiny. It is important for us to continue to develop our own specialist services so that young people do not need to be sent abroad. Our new paediatric hospital as well as the new forensic hospital will provide much needed support. In addition there is the development of clinical programmes around eating disorders, dual-diagnosis, self-harm, all of which, we know, affect our young people. Where that is not possible and our young people are sent abroad, they are monitored closely. I am assured by the HSE that any young person who is abroad is monitored closely.

Where concerns are raised, as has happened with this "Dispatches" programme, all of these issues are investigated. I am assured that no issues have been raised in respect of the three young people who are there and that there have been no problems. The matter will be kept under close scrutiny and monitored.