Years after his death, a mother still doesn't know how mental health services failed her son
The Years Elaine Shows Right Brothers The Clear Photo: Rory Is Hugging Life Rory Holding Own Son Her Rory Eight Hogan Photograph And His Elaine's With The Ago On Moya Nolan Dan Took Son Dan
Over eight years on from her son’s death by suicide, Elaine Clear is still seeking answers as to why the children’s mental health services he attended were not able to help him.
Sitting by the fire in her home, she flicks through a memory book recently compiled by her son Dan Hogan’s friends. “It’s still so unexpected, it’s eight years,” she said. “It’s still shocking, it’s like a bomb goes off and everything is changed.”
Everything changed for those who loved Dan, but she is sure not enough has changed in the mental health services. Weeks before he died aged 17, Dan bluntly told her after a month-long stay in a mental health facility that if this was all the help available, he was “f***ed”.
She remembers six months before he died Dan was elected class rep at the school he loved, he was seeing someone, playing rugby. His friends thronged the family home while he was alive, and she said hundreds passed through to pay respects after he died.
Her questions and those of her other son Rory Hogan are about what happened during the four years Dan was treated by the Child and Adolescent Mental Health Services, a time she describes as Dan’s “parallel life”.
The family endured an inquest in 2016 which, she says, brought no change. She points to the limitations of hospital emergency departments for mental health crises, asking for dedicated mental health emergency departments.
They have met with healthcare professionals, managers, politicians, anyone who might listen, and some have done so. Others, not so much. Rory recalled of one recent meeting: “Their whole mission in that meeting was to calm down what they would have considered a hysterical mother.”
About three weeks before he died in July 2014, Dan spent a month as an inpatient at St Vincent’s Hospital, Fairview, part of the Dublin North Central Mental Health Services from May 20 to June 16. This hospital hosts St Joseph’s Adolescent Inpatient Unit which has been the main focus of the family’s calls for change.
“There is a ban against any parent remaining with their kid overnight," Elaine said. "As a nurse, I have never encountered that while a kid was in deep distress. They undid all the caring I did for Dan. On discharge, he said: 'If that’s the help, then I’m f***ed.'"
Extracts of letters he wrote as a patient and shortly afterwards show he felt “alone” and “traumatised”. Read to the by his mother, he described the atmosphere as prison-like, not the gentle therapeutic help he had expected.
“He constantly and consistently expressed his need to go home and be with his family,” Elaine said. “Each of the reports for Dan’s inquest, from the multidisciplinary team in St Joseph’s unit, all described Dan’s homesickness.” The overnight rules have not changed.
A spokesman for the HSE community health region covering Dublin North City and County, which includes this facility, said they cannot comment on individual cases but that a visitor’s room is provided on-site.
“Residents can meet in private unless there is an identified risk to the resident, an identified risk to others or a health and safety risk,” he said, explaining longer family visits can be accommodated on request.
On hearing this Elaine said this room does not have a bed and is aimed at day-visits. She accepted that in some cases overnight visits would not be suitable, but queried the “blanket ban”.
“We needed to remain by Dan’s side,” she said.
"The tragedy for us is that there was a large, soft, leather sofa chair in Dan’s room that I could have sat in while he slept. I was not permitted to be with my son at a time when he needed me the most."
The family also question the supports provided when he was discharged. A series of meetings with staff never raised one crucial issue, she said. It was only in 2018 while listening to a radio show she discovered there is a statistically higher risk of suicide on discharge from a mental health in-patient facility.
She said quietly: “This information, I believe, is important to inform parents.” The day Dan died, she was in Portugal, helping supervise her younger son and his friends on a post-Junior Cert exam holiday.
“I told myself that I had two sons and I should give Rory the same opportunity I gave Dan after he completed his Junior Cert. I believe that if I had not gone away but had stayed at home, Dan wouldn’t have ended his life at that point,” she said.
A study published in the British Journal of Psychiatry in August, one of many on this topic, said “recently discharged adults at any age are at increased risk of dying from external and natural causes, indicating the importance of close monitoring and provision of optimal support to all such patients, particularly during the first three months post-discharge.”
Elaine and Rory also urged services to share more information with families around how in-patient stays are arranged. Dan was referred to this facility by his CAMHS service, accompanied by family members on the day he was admitted.
Elaine, who was not there but was on the phone with them, said the family’s understanding remains he was not admitted on a voluntary basis. “We were told that if he did not sign the form, they would get a court order,” she said.
She wonders how many parents still come up against these decisions today. “It’s a one-size-fits-all treatment for these young people,” she said. “We felt powerless in our belief, at the time, they were the experts and we had no prior knowledge of psychosis or its treatment.”
Factors around admission include the level of risk, the parents’ ability or agreement to support an admission, the HSE spokesman said, adding: “It is a complex clinical decision”. He clarified ‘a court order’ is an application by a psychiatrist for an involuntary admission of a child under the Mental Health Act 2001 if this is in the child’s best interests.
“If a young person is admitted on a voluntary basis, and parents change their minds and wish to take their child home against the recommendations of the clinical team and consultant psychiatrist, in many cases this can be facilitated,” he said.
Dan's death came before the coroner's court in March 2016, with the jury returning a verdict of death by suicide. “The inquest had no impact, none, nada,” Elaine says now.
Dan’s parents had made two recommendations to the jury. They asked parents be allowed remain with their child overnight in a mental health facility if appropriate.
They also asked that parents be warned on discharge from an in-patient psychiatric unit that there is an increased risk of suicide.
The jury recommended an adult family member be permitted to stay with a patient in a psychiatric unit if professionals deem it helpful during the admission process and facilities are available.
The family have questions too about the value of the years Dan spent in community care, attending CAMHS at Lucena Clinic in Dublin.
In January, the South Kerry CAMHS came under fierce scrutiny in the Maskey Report, leading to a national audit of prescribing practices. Reading this brought up distressing memories for Elaine.
“I am so sad and angry that my gorgeous boy was subjected to all that inadequacy,” she said. “He sought so hard to overcome his anxiety and now I see what we were up against.” A “deeper root-and-branch review” is needed, she urged.
“I hope they address the issue of prescribing tranquilisers for young people with anxiety issues as a first step, rather than or in conjunction with talk therapy with a psychotherapist of their choice,” she said.
“The control of CAMHS by psychiatry is the first step needing reform."
She is doubtful about the value of research, being undertaken with University College Cork as part of a response to the Maskey Report, might turn out to be.
Answering questions from the , the HSE said: "An academic partner has been engaged to conduct qualitative research to include the lived experience of service users, families and carers, staff, referrers and other key stakeholders interacting with the CAMHS service.”
It is expected to be complete within six months from confirmation of ethical approval.
Elaine said: "I support research that supports service users, both young people and their families. However, in my experience, and of others, when you are in the CAMHS service because your kid is feeling vulnerable, at risk of feeling stigmatised or of being isolated, there is great pressure on parents to not criticise the service.”
Rory also wonders if his older brother could have been treated differently with more emphasis on counselling or therapy.
“What they have is not tailored to individuals, the whole set-up has to be reformed,” he said. “It has to be tailored and I don’t think they have the [staffing] capacity to do that.”
Starting in 2013, the family also sent Dan to a private therapist outside of Dublin. She remembers the long drives with affection now, recalling how relaxed her son was after the sessions, but also her frustration at not being able to afford this treatment more regularly. Rory says this therapist “gauged Dan’s needs, they chatted”, which allowed his brother to open up.
Following Dan’s death, the family agreed to take part in a review with Lucena. Elaine and her then-husband John were interviewed before the inquest.
It was only in 2020, during a meeting with the family and after many requests, that a report was shared indicating the process had been halted until the in-patient service either joined this review or began their own.
“It took St John of God CAMHS four-and-a-half years to do a report on Dan’s time with them,” she said. “Why didn’t they do (finish) that report on Dan?” The family remain confused to this day. A spokesman for Lucena said they cannot comment on individual cases.
The clinic was audited in July as part of the Maskey response. “While the official report is still awaited, we anticipate it will acknowledge that the service is significantly underfunded. Staffing currently equates to just 56% of that outlined under the Vision for Change guidance on recommended staffing levels,” the spokesman said.
Results of a medication audit are also expected. “The Service has not been alerted to any concerns around excessive medication or dosages used in the Lucena Clinic CAMHS,” he said.
Today with their hopes dashed that changes could have been introduced for in-patient services after the inquest, Elaine and Rory would like to see dedicated emergency departments for mental health patients.
Elaine remembers taking Dan to a hospital ED when his anxiety worsened in 2014; he left without being treated after waiting over five hours. Rory joins in to say the typical ED spaces are just not suitable for mental health patients, there is “too much going on”.
The HSE said for people attending ED in a mental health crisis or experiencing urgent physical and mental health needs “it is critical that a specialist service is available that is provided in a suitable environment for an individual in distress."
The spokesperson said liaison mental health services (LMHS) provide this for people of all ages.
The LMHS offers services for people who come to an ED after self-harming and these are delivered in accordance with guidelines from the National Clinical Programme (NCP), the spokesperson said.
The ‘NCP self harm and suicide-related ideation’ was introduced in 2014, the spokesperson said, and now runs in 25 adult EDs operating 24/7 with planning for more sites. “In addition, there are posts funded in three Dublin paediatric hospitals with posts filled in two sites at present,” the HSE said.
The year 2014 was when Dan passed away. The family welcomed these changes and the increase in specialist nurses known as SCAN (suicide crisis assessment nurses) but said this does not go far enough.
“An ordinary emergency department is not kitted out for mental health patients,” Elaine said. “What is needed is a mental health emergency department where people can go if they feel suicidal.” It is a clear issue; suicidal ideation is not, in itself, a criterion for access to CAMHS.
HSE data shows that, as of September, 3,818 children were on the CAMHS waiting list, just over 10% of whom have been waiting a year. There have been improvements in tackling the waiting list, but problems persist at the next level below CAMHS for intervention.
Wait times for Jigsaw child and adolescent services have increased this year in 10 of the 14 areas in which it operates and almost tripled in Cork, from 11 weeks last year to 29 this year.
The importance of Jigsaw is outlined by research published in October which showed children as young as 12 among the 1,083 young people seen by Jigsaw who had expressed a desire to hurt themselves, with data over a seven-year period analysed.
Elaine referred to Maxine Maguire, who died by suicide in 2017 and whose family have spoken publicly of frustrations similar to those felt by Dan’s family, including to the last March.
“The national clinical programme (for self-harm) is aspirational,” Elaine said. “Maxine Maguire died because she did not receive any ‘bridging to next care’. I could name others, but her parents went public about the absence of mental health care.”
She believes that, at the time of Dan's care, he fell between what she said was the "blatant gap" between adolescent and adult mental health services.
A senior child and adolescent psychotherapist, who wished to comment anonymously, told the the first thing any young person feeling suicidal needs is prompt access to the right support - "and often this isn’t available”.
"The waiting lists and demand for services is getting worse year-on-year and supply seems nowhere near enough to meet demand," they said.
"However the answer may not be to just develop more mental health services, there is an argument to be made that the societal factors that are leading young people to experience suicidal thoughts needs to be addressed."
The psychotherapist said there are "huge benefits to talk therapies for many teenagers", but for others medication and other specialised therapeutic interventions are necessary, alongside therapy.
"The demand for services is varied and therefore the supply of services needs to be varied too. Some people will require a medical model of treatment, but others don’t," they said.
"We need to develop services to meet the wide breadth of mental health needs rather than expecting one service to be the catch-all for everyone.
“Young people have health, educational and social needs and if we could signpost people to the correct service to meet their needs from the start, and services were willing to work together then this would go a long way to addressing the problems."
For Elaine, the sense of grief is very real, matched by a yearning for change.
“Maybe there is something I can do because I’ve nothing to lose anymore, that’s been my attitude,” she said, explaining while her son was in the services she felt she could not complain.
“Dan wanted so much to get control over this anxiety that played havoc with him. The help he sought did not in any way resemble the help he got. He had asked for help, not punishment.”