Taoiseach Micheál Martin has described a review of the care of more than 1,300 children who attended the HSE-run South Kerry Child and Adolescent Mental Health Service (CAMHS) as "very, very serious" and "unacceptable".

Micheál Martin said the report's finding that 46 children suffered significant harm was a "profoundly serious issue", adding that "it demands a fundamental review" right across the country.

The Taoiseach told the Dáil that the report is a "damning indictment of the service" provided under CAMHS in South Kerry.

Mr Martin said: "Following the publication of the report there will be a full audit nationwide of compliance with CAMHS operational guidelines by all CAMHS teams.

"In addition, a prescribing audit will be conducted in each of the 72 CAMHS teams to include a random selection of files proportionate to the medical caseload from a continuous six-month predefined time period in 2021."

He was replying to the Social Democrats co-leader Róisín Shortall who said the report was "really quite shocking". She said the fact that 46 children suffered significant harm was "unimaginable" for the families.

She said it demanded a "wider inquiry" than just south Kerry, adding it also raised "very serious concerns about management within the HSE" because the whistleblower "resigned from the HSE because he received no support, and was sidelined after raising concerns."

Ms Shortall said it was "really important" this happened because "too often" managers focused on "silencing whistleblowers rather than encouraging them".

She said the report also revealed an "entirely chaotic system" in which were was still no child and adolescent consultant in south Kerry since 2016.

Read the full report here

The Taoiseach said the absence of a consultant was not a "resources issue" - rather there has been "ongoing difficulties" in recruiting for such posts "in certain parts of the country."

He said it was also "very important" to say: it's not the parents fault.

Mr Martin said he retained an "open mind" about what needed to be done; he said there had to be an "end-to-end review"; and this would include the issue of whistleblowers.

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'Clear evidence' 46 children suffered significant harm

He was speaking after a review of the care of more than 1,300 children who attended the HSE-run CAMHS centre in south Kerry found there was clear evidence that 46 of them suffered significant harm.

The review also found that 227 children being treated by a junior doctor employed by the service had been exposed to the risk of significant harm through the doctor's diagnoses and treatment of them.

There was no system to check the prescribing of medications or the quality of service by the junior doctor's supervisors.

Of the 46 children in the cases reviewed deemed to have suffered significant harm, considerable weight gain, sedation during daytime and elevated blood pressure. The report says the figure of 46 is likely to change, as new information becomes available.

Of the 227 children exposed to the risk of serious harm while they were under the care of the junior doctor, issues included sedation, emotional and cognitive blunting, growth disturbance, serious weight changes, metabolic and endocrinal disturbance and psychological distress.

The report says these children were exposed to risk of harm by the junior doctor because of a lack of knowledge about the best way to do things.

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Concerns expressed about the doctor, who is not identified in the report, led to the establishment of the review in April of last year. The doctor did not co-operate with the review.

The review also found that another 13 children had been unnecessarily exposed to a risk of harm while under the care of other doctors in the service.

The HSE has published the report of the review, having sent it to the families of the 227 children involved, along with letters of apology to them.

The review covered the period between 1 July 2016, and 19 April 2021. It was conducted by a team of 13, led by London-based consultant child and adolescent psychiatrist, Dr Sean Maskey.

The review identified supervision as a serious issue in CAMHS in South Kerry, along with an absence of checks by a governance group that the Child and Adolescent Services team in South Kerry was working safely and effectively.

It found the CAMHS team in the area had no clinical lead and no consultant child and adolescent psychiatrist. It said the absence of a clinical lead was one of the reasons for failing to provide and keep a high quality service.

Another child and adolescent psychiatrist temporarily covered the vacant position of child and adolescent psychiatrist in South Kerry CAMHS, but the vacancy took much longer to fill than had been expected.

The review found that the consultant child and adolescent psychiatrist supervising the junior doctor did not see problems that developed throughout 2017 and again throughout 2018.

The report says concerns about the junior doctor were first reported in 2018.

"No proof was found that these concerns were addressed after being reported," the report states.

The review found that concerns about the doctor's prescribing of medication were "clear" in 2019.

"The supervisor at the time advised changes but did not insist these happened," the report says.

The junior doctor worked overtime and was observed to be very tired at work.

"This issue was not addressed," the report says.

Notwithstanding the concerns that were raised, the junior doctor was recommended for other jobs in 2020.

A new senior medical manager started work with South Kerry Child and Adolescent Mental Health Services, but concerns about the junior doctor were not passed on to the new manager.

The report says South Kerry Child and Adult Mental Health Services had not put in place many of the recommendations of the national CAMHS operating procedure of 2015, or the CAMHS Operational Guide of 2019.

It said the CAMHS team in South Kerry had not named key workers to all cases, had not named a team co-ordinator and had not named a practice manager. It said the team had a lot more referrals of new patients than other services across the country, and that the number of referrals had not reduced at the same rate as other services.

The review identified "unsafe" practices, such as rules for the keeping of case files were not being followed properly, and doctors and staff were able to take files from the file room without signing them out.

The review found "proof" that ten full case records were missing. Two referrals were also missing.

In addition, clinical information was not always recorded on patients' files.

The report makes 35 recommendations.

The HSE is operating an information line for those affected - 1800 742 800 - which is open from 8am to 8pm, seven days a week.