A report has found there was a failure to act by two public psychiatric hospitals in Tipperary on a report concerning fractures sustained by 19 residents.

The report of Mental Health Commission's inquiry into care and treatment practices at the hospitals found they failed to act on a clinical risk management report in September 2004.

The Commission has announced today that it proposes to attach conditions to the continued operation of St Luke's Hospital in Clonmel and St Michael's Unit at South Tipperary General, and the HSE has been given time to respond to this move.

The Health Service Executive is now required to deal with breaches of regulations and codes of practice found during an inspection late last year.

The 196-page inquiry report concludes that the safety and welfare of residents was not given the highest priority at two facilities.

It says that a September 2004 report on fractures, which occurred between July 2002 and January 2004, was not considered until nearly a year later.

When considered, it was at a meeting that lacked purpose, that was not minuted and which failed to initiate actions to deal with the findings and recommendations of the report.

There was a failure to act on concerns about the lack of activity, exercise and caring for frail and potentially aggressive residents together, that would be likely to increase the risk of injury to residents.

The inquiry says that staffing shortages, the physical environment and outdated practices were the principal reasons why individual patient care was not at the heart of the system in the hospitals.

It found that a combination of staffing constraints and environmental defects appears to have increased the risk of injury to residents.

It also says the lives of residents were adversely affected by the unnecessary locking of ward doors at St Luke's Hospital in Clonmel.

Residents were also affected by unnecessary use of seclusion and the nursing of residents in night-clothes at St Michael's Unit at South Tipperary General.

The inquiry has recommended a series of time bound measures to be taken by management at the two hospitals including measures relating to seclusion, restraint and the prescription of drugs.