RTÉ’s This Week has seen an unpublished HSE report into the Carlow Kilkenny South Tipperary Mental Health Service (CKST MHS) which calls for wide-ranging changes in response to concerns over patient deaths and an ongoing dispute between consultants and management over clinical governance.

The report demands immediate attention be given to a cluster of 13 fatalities among patients and service users, which had been highlighted by nine consultants in the service.

The report into Clinical Governance in the CKST area also describes the disengagement from local management groups by the same nine senior doctors as a “dangerous and unacceptable risk to the CKST Mental Health Service”.

The report authored by Dr Colm Henry, the HSE National Clinical Lead and Cork-based Consultant Psychiatrist Eamon Moloney, is titled the ‘Review of Governance structures within Carlow/Kilkenny/South Tipperary Mental Health Services’ (the CKST Review).

The CKST Review notes that “Some consultants have informed us that participation in governance structures became futile as concerns they raised were not addressed”.

Among the consultants’ concerns was the conduct of investigation into patient deaths.

Speaking to This Week on Sunday, Dr Henry confirmed that investigations into the deaths of the 13 patients and service users are currently being re-examined: “We did make a strong recommendation that all of the cases that led to the consultants concerns be reviewed and all of the process of the original investigation reviewed and any learning points fed back to the clinicians concerned.

"My understanding is that this has taken place and that some of the individual case reviews are completed and others are nearing completion”.

The CKST Review recommends that any such reviews, when completed, be made immediately available to the consultants.

The doctors had previously complained about being unable to access the results of such reviews.

RTÉ's This Week understands that consultants resorted to the Freedom of Information Act to get copies of reports into patient deaths, which ultimately took six months.

Separate documents released to This Week under FOI show that January 2013, the consultant’s disengagement from clinical governance meetings was recorded in the Risk Register of CKST MHS as “a risk to patients and service users”.

The register also records a “Possible risk of adverse events” and “Reputation Damage” as a result of the consultants’ actions.

However the CKST Review examined minutes of meetings and found no evidence of the matter being discussed further at meetings about risk management.

While they continued treating patients and carrying out clinical duties, the withdrawal by nine of the twelve consultant psychiatrists in the CKST MHS from governance structures formally began in November 2012.

In a letter to the Local Area Manager they outlined that they were withdrawing confidence in the Clinical Management of the service.

The letter was copied to Dr Philip Crowley, the HSE’s Director of Quality and Patient Safety at the Executive’s headquarters in Dublin.

In response to the letter from the consultants to the HSE, the executive says local management engaged with clinicians on a number of occasions regarding the issues they raised. 

However, unsatisfied by the response by the HSE, the consultants then wrote to other managers at the most senior levels of the Executive, including the Director General Tony O’Brien.

They also wrote to ministers James Reilly and Kathleen Lynch at the Department of Health to outline their concern over a lack of transparency in dealing with suicides and other serious incidents.

They also stated that they believed governance in the CKST service was “unsafe”.

In the letter to Kathleen Lynch, the doctors repeatedly questioned the safety of governance in the service and said they felt “devalued” and “ignored” in their attempts to raise their concerns internally in the HSE.

The letter details the consultants’ view of how the issues they had raised were treated by the HSE since their November 2012 correspondence with the Local Area Manager.

They outlined the Serious Untoward Incidents (SUI’s) they raised, including nine fatalities in the 14 months from August 2011 to January 2013.

Among these were three suicides of in-patients by the same means; 4 suicides in home-based settings and a further suicide in a ‘crisis house’ setting in the community.

The consultants also expressed concern over the conduct of investigations into SUI’s which included suicide, homicide, assaults and episodes of self harm.

In their June 2013 letter the doctors also called on Minister Lynch to intervene with the HSE to ensure proper investigation of incidents and for review findings to be properly communicated and appropriate reforms implemented.

The consultants also told the Minister that they were never informed of the outcome of reviews of the serious incidents (which they would ultimately get under FOI six months later).

Unreleased figures compiled for the Mental Health Commission seen by RTÉ's This Week show a further four service users have died since the consultants June 2013 letter was sent.

Minister Lynch’s reply to the consultants was issued on 20 June 2014, almost one year later. However, Kathleen Lynch has previously told This Week that she asked the HSE to look into it at the time, but did not feel at the time it required an examination from outside the service.

Other HSE sources have previously told This Week that CKST in-patient death-rates are not out of line with international norms or other service areas.

However, Dr Colm Henry and Dr Eamon Moloney in their CKST Governance Review document say “a benchmark for comparison with other MHS (Mental Health Services) is not possible”.

Asked if he shared the concerns of the consultants over the length of time taken to respond to the consultants’ concerns, Dr Colm Henry who co-authored the CKST Review told This Week: "Well, we’ve detailed the sequence of events [in the CKST Review] and it’s clear that part of that sequence and narrative does show that there was a delay in addressing their concerns and that led to how myself and Dr Moloney became involved and I can’t explain that."

Dr Henry and Dr Moloney’s CKST Review also recommends changes to how serious incidents are investigated, including the setting up of a Quality and Safety Executive Committee (QSEC) to replace the risk management structures currently in existence.

The Review calls for strong consultant representation in smaller groups to replace the current larger local groups, which the Review describes as being too big to be effective.

These groups should ensure that “all incidents are managed and investigated satisfactorily”, according to the document.

The Review also recommends that any decision by local managers not to investigate serious incidents further should be reviewed by the QSEC.

In relation to consultants concerns over the conduct of investigations into patient deaths by consultants involved at the time of death, the CKST Review calls for external expertise to be brought in.

It further recommends that doctors overseeing patients during a serious incident should not be involved in investigations into patient deaths.

Dr Henry said on Sunday “It’s quite clear if you’re a clinician involved in the care of a patient you shouldn’t be involved in the investigation if something goes wrong.

Clearly you have to contribute to the investigation and you have to give information. In terms of managing the investigation, it’s good practice and good governance for that to go to somebody else”.

An external implementation group to oversee the implementation of the CKST Review’s recommendations is also called for in the document.

As well as repeatedly calling for the re-engagement of consultants in the clinical governance structures in the CKST area, the Review calls for “thorough analysis and action plan, involving escalation if necessary” if they do not participate.

Speaking to This Week, Dr Henry repeated the call: “Dr Moloney and I feel strongly that consultants should re-engage with fully this structure in the interests of patients and their families.

"We have stated very strongly where we think things must improve and must get better and we have, I hope demonstrated a pathway to how this can take place, to how they can re-engage”.