Taoiseach pledges full audit of Kerry Camhs after 'unacceptable' findings of report 

"I have read the executive summary of the report. It is shocking and very serious," he said

What happened is unacceptable. It represents a damning indictment of the service. The first principle of medicine is to do no harm. Children were harmed here by a complete failure of clinical performance and oversight and by the entire management of the service.

Mr Martin said that the report "demands a fundamental review", not just of south Kerry. He said that it "is not a resources issue" and that the resources "are there to make appointments".

"It is important to say that it is not the parents’ fault, because many are feeling guilty. 

"I watched one parent last evening on the "Six One News" say that she was taking on some of the guilt herself regarding what had happened. It is not the parents’ fault, though, because they will go by what is indicated or advised by the treating clinician.

"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. It will include a random selection of files proportional to the medical caseload from a continuous six-month predefined period in 2021."

46 children suffered 'significant harm' under the care of Kerry Camhs

Some 46 children suffered “significant harm” while under the care of Camhs, a review of more than 1,300 children who attended the service has found.

These harms included galactorrhoea (the production of breast milk), significant weight gain, sedation and elevated blood pressure.

The review also found that some 240 young people received substandard care.

Consultant paediatric psychiatrist Dr Seán Maskey, who led the review, found “unreliable diagnoses, inappropriate prescriptions and poor monitoring of treatment and potential adverse effects” exposed many children unnecessarily to the risk of significant harm.

And 227 children were exposed to the risk of significant harm by their diagnoses and treatment by a junior doctor in the service.

Of these children, issues they experienced included sedation, emotional and cognitive blunting, growth disturbance, serious weight changes, metabolic and endocrinal disturbance and psychological distress.

The junior doctor lacked appropriate knowledge and there was no system to check on his prescribing practice or quality of service, the report found.

The review was established last April following concerns raised about this doctor, who is not named in the report.

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 review covered the period between July 1, 2016, and April 19, 2021.

The HSE had apologised to impacted families and opened an information line for them in April on 1800 742 800.

The report was commissioned by Michael Fitzgerald, chief officer of Cork Kerry Community Healthcare, which has responsibility for HSE mental health services in Kerry.

Mr Fitzgerald said on Wednesday: “Young people and their families are entitled to expect a high standard of care when they attend our services, and the report makes it clear that this did not happen in a large number of cases. 

As chief officer of the organisation, I apologise sincerely to the young people and their families for this. I want to reassure the young people and their families that we have taken on board the 35 recommendations in the report, and will implement them as quickly as we can.” 

Despite repeated calls for improved staffing, the service still does not have a full-time clinical psychiatrist, it is understood.

The College of Psychiatrists of Ireland cautioned that the broader recruitment and retention crisis in mental health was a significant contributing factor in the case.

It also said the inappropriate prescription of multiple medications to young mental health patients was highly disturbing and distressing and demands accountability.

Speaking on Wednesday, Dr William Flannery, consultant psychiatrist and president of the College of Psychiatrists of Ireland, said: “This case is highly disturbing, will be a cause of huge distress for families involved and personal responsibility is of course paramount here. However, the specifics of this case cannot be separated from the broader recruitment and retention crisis in our mental health services at present, which is having a significant negative effect on patients.”