A report by the Mental Health Commission, which arose from a number of deaths in Carlow, Kilkenny and south Tipperary, has found that clinical staff might have been alerted to the risk of patient suicide if proper assessments had been carried out.

The report was ordered after 13 people died by apparent suicide while under the care of mental health services in the area between January 2012 and March 2014.

It is the second examination of mental health services in Carlow, Kilkenny and south Tipperary.

It follows on from a Health Service Executive report into a cluster of deaths in the area between 2012 and 2014 involving people under the care of the mental health service there.

The commission's targeted intervention involved carrying out a review of the problems, making recommendations and following up with the HSE to ensure that action was taken.

It found that clinicians might have been alerted to the risk of patient suicide if adequate assessments had been carried out.

It also concluded that training for risk assessment was either insufficient or else it was not being applied in all cases.

It found that newly presenting 16- and 17-year-olds in south Tipperary were not receiving a safe and adequate service.

There was also a practice of transferring residents from hospital to community care to free up bed space.

The commission made 19 recommendations; 12 have been implemented and implementation of the remaining seven is under way.

Mental Health Commission Chairman John Saunders said the commission became aware of a number of apparent suicides over a 27-month period.

Speaking on RTÉ’s Morning Ireland, he said it also learnt of other untoward incidents and accidents which brought concerns to the commission that all was not well.

There were incidents where patients suffered accidents which were not treated appropriately, including where a person suffered self injury through burns and serious assaults on staff.

He said the Inspectorate had found that across the system there were inconsistent approaches to the assessment of suicidality.

Some patients received a very good assessment, others received a shorter form, he said.

They found that the level of training and ability to assess was also at variance across the region.

The root of the problem was around communication and teamwork, he said.

He said he was satisfied the issues had been largely resolved but the situation would continue to be monitored.