Official Report (Hansard)

Session: 2007/2008

Date: 01 May 2008



Madeleine O’Neill and Lauren O’Neill

1 May 2008

Members present for all or part of the proceedings: 
Mrs Iris Robinson (Chairperson) 
Mrs Michelle O’Neill (Deputy Chairperson) 
Mr Thomas Buchanan 
Dr Kieran Deeny 
Mr Alex Easton 
Mrs Carmel Hanna 
Mr John McCallister 
Ms Carál Ní Chuilín

Mr Hugh Connor ) Eastern Health and Social Services Board 
Dr Paula Kilbane )

Mr Dominic Burke ) Western Health and Social Services Board 
Mr Michael Gormley )

The Chairperson (Mrs I Robinson):
I welcome Mr Dominic Burke, acting chief executive of the Western Health and Social Services Board; Dr Paula Kilbane, chief executive of the Eastern Health and Social Services Board; Mr Hugh Connor, director of social services at the Eastern Health and Social Services Board; and Mr Michael Gormley, head of consumer services at the Western Health and Social Services Board. You are all very welcome today, and the Committee looks forward to hearing your presentation.

Mr Dominic Burke (Western Health and Social Services Board):
I thank the Chairperson and the members of the Committee for inviting us here today. We hope that the Committee has found the written submissions that we have sent you useful in giving you some background to this case.

The independent inquiry panel identified a series of failures in Madeleine’s care and treatment, and also in the protection of Lauren. It is apparent that Madeleine was not given the appropriate care to which she was entitled, and vital information in relation to the dangers to Lauren did not appear to come to the attention of the relevant staff.

Dr Kilbane and I, and our colleagues in the Western and Eastern Heath and Social Services Boards, are deeply sorry for the pain and loss suffered by the families of Madeleine and Lauren as a result of these failures. We are determined to continue to work with the relevant parties in health and social care, and with other agencies, to ensure that the inquiry panel’s recommendations are fully implemented.

I will now outline the background to the tragic deaths of Madeleine and Lauren. Following that, I will summarise the major findings of the independent inquiry. Finally, I will briefly describe the statutory responsibilities of the Department and of the health and social care organisations — particularly in relation to children and vulnerable adults. Dr Kilbane will focus on the actions taken by the Western and Eastern Boards and will outline the work currently being done to implement the independent inquiry’s recommendations.

Madeleine O’Neill and her nine-year-old daughter Lauren died on 12 July 2005. A coroner’s inquest has yet to be held, but, from evidence obtained from the PSNI, it would appear that Madeleine took her daughter’s life and then her own. Madeleine had been suffering from depression for a number of years prior to 2005 and was being treated for this by her GP. Following a marital separation early in 2005, she attempted suicide in May. Following a short stay in Belfast City Hospital, Madeleine was referred to, and visited by, community-based staff from the former South and East Belfast Health and Social Services Trust.

Early in June 2005, Madeleine was again having suicidal thoughts and she made reference to taking Lauren with her. Following intervention by her private counsellor and her GP, she was admitted as a voluntary inpatient to Knockbracken Healthcare Park on 9 June 2005. Madeleine’s parents, who lived in Derry, had been staying with their daughter when she was ill. With the agreement of the consultant medical staff in both Knockbracken and Gransha Hospital, Madeleine was transferred to Gransha Hospital on 14 June. She remained there as a voluntary inpatient until 27 June, when she was discharged. On 12 July, the bodies of Madeleine and Lauren were discovered in their home in Carryduff. There is a detailed timeline in the report; I will not go through it, but if you have any questions about it we will pick them up.

After discussions with the Department, the two boards commissioned a joint independent inquiry panel in spring 2006. The panel provided its report, in confidence, to the boards in May 2007; the report was made public in 2008.

The independent inquiry panel found that communication between professionals in relation to hospital admissions and transfers, between consultant medical staff, between hospitals, and between professionals and relatives were potential weaknesses in the process during the management of the care offered to Madeleine and her daughter. The child protection issue and the failure to recognise the important relationship between child protection and mental health — particularly in light of Madeleine’s comments in hospital in Belfast and to her GP — are significant. The competence, training and education of staff in mental-health care were recognised as common themes, and the report highlighted a lack of understanding of severe mental illness.

I have referred to child protection, but there is also an interface between mental-health care and childcare. The panel found that mental-health staff focused entirely on Madeleine and failed to consider the needs of Lauren or, indeed, involve Lauren’s father in her welfare and care. The panel felt that the care and discharge planning fell far short of requirements.

In terms of consultation with and support to the families, a general failure to involve Madeleine’s relatives in discussions about her care and treatment was identified. The panel felt that, at various times between May and July 2005, there were a number of opportunities to take appropriate action that might have prevented the tragic deaths of Madeleine, Lauren, or both on 12 July 2005.

I will outline briefly the statutory responsibilities of the Department and health and social services organisations. As the Committee knows, the Government must exercise its powers to safeguard and promote the welfare of children and vulnerable adults through statutory agencies. That responsibility is enshrined in legislation, which specifies, in broad terms, what is required to safeguard and promote the welfare of children and vulnerable adults, and outlines the organisations responsible for the discharge of statutory functions.

The role of the Department is, mainly, to ensure that we have appropriate legislation and a strategic policy direction that enables us to satisfy that legislation. That requires the establishment of regional priorities, setting of targets and provision of resources. The Department has a duty to ensure the quality of good governance in health and social services.

The boards are responsible for commissioning services to meet the needs of the population and for ensuring appropriately defined performance and financial management standards. To that end, there are schemes of delegation of statutory functions, which are identified and agreed between trusts, boards and, subsequently, the Department. Each board must ensure that the standards are adhered to in the delivery of services by the trusts. The boards prescribe professional quality standards, approve policies and procedures, monitor and evaluate services, and satisfy themselves as to the arrangements that trusts put in place for quality assurance. It is the board’s responsibility to monitor those schemes and ensure that they are updated biannually. The trusts are responsible for the exercise of all relevant delegated functions, and they ensure the discharge of those functions in accordance with the approved schemes.

I have here a scheme agreed between the Eastern Board and the Belfast Health and Social Care Trust. Committee members can have a copy if they wish, just to see what we are talking about as well as the breadth of legislation and responsibilities that are contained in these schemes.

As separate legal entities, trusts are accountable for a range of functions such as compliance, monitoring and reporting arrangements. It is essential that those duties be carried out to the highest professional standard. Trusts must also assist the boards and the Department in discharging the functions that have not been delegated, and for which they are not legally responsible.

That clarifies the different levels of responsibility, but the bottom line is that we must work together to ensure the delivery of effective services.

Dr Paula Kilbane (Eastern Health and Social Services Board):
I join with my colleague from the Western Board in extending our sympathy to the O’Neill and Gormley families, who have had to deal with a tragedy that is inconceivable, particularly for those here who have children. It is an immensely sad situation, and we cannot apologise enough for the failings that led to the tragedy.

The boards have four duties in these situations: the first one is to commission an inquiry; the second is to quality assure, accept and disseminate any reports that are produced by the inquiry; the third, which also applies to trusts as separate employing organisations, is to determine as an employer whether any disciplinary action or referral to regulatory bodies might be required as a result of the findings in such reports; and the fourth duty, which is crucial, is to oversee and play a direct part in the implementation of the recommendations of such reports.

This report was commissioned under the 2004 departmental guidance on discharge from hospital and the continuing care in the community of people with a mental disorder who present a risk of serious physical harm to themselves or others. That guidance requires boards to establish an independent panel in cases where a person who has been in receipt of mental-health services takes another person’s life. As it was a child who lost her life in this case, the two boards were also required — under the co-operating to safeguard guidance in child protection — to carry out a case management review.

From the outset, the two boards and the Department believed that having one process that wove together those two strands would provide a comprehensive picture of what happened. Therefore, the two boards established a unique independent inquiry panel to undertake both tasks. The boards agreed the membership of the panel, which, as set out in the report, was appropriately multidisciplinary and specialist and had independent input. The panel produced a remit, which was agreed with the Department, and began its work on 4 May 2006.

Having ensured that the report of the independent inquiry panel had addressed its remit, the boards accepted the report in confidence on 10 May 2007. As I said, boards have a key duty to distribute and disseminate reports to ensure that lessons are learnt throughout the Health Service. By commissioning these inquiries, we are trying to ensure that we understand fully how to prevent similar tragedies. In that role, dissemination of the findings is important. Once launched into the public arena, the report was put immediately on our websites. There has been unprecedented disclosure of the findings of this report, which is right and proper.

Committee members may question why, having received the report in confidence on 10 May 2007, we did not find it possible to launch the report until one month ago. There were two reasons for that: we needed to involve the trusts and health and personal social services in the matter, and we also had to liaise with the PSNI and the coroner. Throughout the process, we were sensitive to the needs of the two bereaved families. Their wishes were taken into account.

We accepted the report on 10 May 2007. Knowing that the timetable for publication would depend on external bodies, there was an issue also about quality assurance. The report was issued to the coroner, the PSNI and the families on that date.

The boards were subsequently informed by the PSNI on 7 November 2007 that no criminal prosecution arising out of the case would be pursued against any individual or corporate body. On 28 November, the coroner wrote to our director of legal services stating that he was content to leave it to the discretion of the two boards to decide when the contents of the panel’s report should be made public. That enabled the boards to plan for publication, which was discussed with the family.

For the record, the coroner indicated to us on 24 April 2008 that he proposes to start the inquest into the case on 1 September 2008. It is my understanding that it is likely that the inquest will last for approximately four weeks. The boards and the trusts will co-operate fully with the coroner in respect of whatever approach he wishes to adopt, because we are conscious that we are in a process that is not yet complete.

I referred to the duty of the boards to make determinations about disciplinary and referral matters vis-á-vis employees. Some of you may be aware that an independent counsellor and a general practitioner were involved in the case. They were involved at an early stage in the sequence of events that led to the deaths of Madeleine and Lauren. Regrettably, both did not follow policy and procedures on child protection. As a consequence, the Eastern Board needed to consider what steps it should take. It invoked its processes for considering the performance of independent contractors in respect of discipline and referral to professional bodies. The family practitioner concerned is in contract with the board; the private counsellor, although not in contract with the board, is an independent practitioner.

We have a clearly-set-out process for dealing with such instances, which involves the reference committee — a committee of the board with responsibilities for considering all disciplinary matters — meeting to consider the actions of the individuals concerned. Following careful consideration, the committee determined that disciplinary action would not be taken against the private counsellor or the general practitioner. However, it made recommendations that contacts between the general medical adviser, the board’s social-services representative, a GP and a private counsellor should take place in order to ensure that professional responsibilities regarding child protection were clearly understood and implemented. Those meetings subsequently took place in July and August 2007.

The matter was also referred to the board’s local advisory investigative panel, which is an advisory group with a broad membership. Part of its remit is to consider clinical performance issues concerning GPs. That group was satisfied that performance issues had been fully addressed. That course of action was reported to the board.

The boards’ role in relation to those staff employed by the trusts who were directly involved in the care of Mrs O’Neill was that both boards wrote formally to the trusts concerned, requesting then to put in place their investigation and procedures vis-à-vis disciplinary and referral matters in relation to the report and its findings. They did that, and they carried out a process under the relevant disciplinary codes, which included referral of their findings to the professional heads in the trusts to determine whether there were any significant failings that warranted disciplinary action. The recommendations of the professional heads were formally considered by the chief executives of the trusts, and their findings were also considered by the respective trust boards. That is an instance of the appropriate governance that we require from people in relation to how they conduct processes vis-à-vis their own employees.

I turn now to the implementation of the recommendations. The Western Board, along with the new Western Health and Social Care Trust, has been working to implement those recommendations that are relevant to the former Foyle Health and Social Services Trust. The improving mental health services project, including senior officers from board and trust, was established to take forward those recommendations. There is a project monitoring board for monitoring progress, and that is overseen at board level by a multi-professional steering group.

Of the 36 recommendations in the full report, 21 focused on the former Foyle Trust, and within the Western Board area, as of today, 10 recommendations have been implemented fully and 11 are progressing. Plans have been put in place to secure full implementation of all the recommendations, and a project manager was appointed in January 2008 to take forward the implementation of the recommendations.

In the Eastern Board area, the new Belfast Trust — in whose premises we are meeting — has been working to implement the recommendations. The report focused on the former South and East Belfast Trust, as members will be aware. However, the review process has had to take into account the implementation of the recommendations right across the breadth of the new trust, which is a large task.

We established a project board with senior directors of our board and the trust to develop a timetable and a plan for actioning the recommendations. That has been monitored and overseen by a small group which has been looking at the reports and has required the collection of evidence to verify progress. That progress has been reported at regular intervals to the Eastern Board.

There were 22 relevant recommendations for the Eastern Board and, as of today, eight of those recommendations have been implemented fully, and 13 have been implemented as fully as they can be at present because they are in stages where, for example, they are trialling a variety of different approaches and so on. We can say more about that if you wish. One recommendation remains as work in progress, with more work required to be done.

The circumstances in which infant or child deaths occur are extremely rare, and the circumstances in which a parent takes the life of a child and their own life are extraordinarily unusual. This is the first occurrence in a generation. Across the UK as a whole, circumstances such as those have occurred on approximately 10 occasions in the past five years.

Be that as it may, the fundamental issue that both boards want to see improved as a legacy of this tragedy is the creation of mental-health services that are much more family-orientated. Achieving that is not simply about adopting new policies and procedures. It will require a major change in ethos that looks at patients, not in isolation, but as members of families — as parents, spouses, daughters and so on — and recognises the impact that mental illness has on children and families. It is not just about the individual but also those close to them.

We must establish much stronger working between mental-health services and family and childcare services. That is critical to identifying children at risk and children in need. That requires a recognition that many more families need support if they are to function successfully, and it needs to be tackled urgently. We will have failed in our duty if we do not act now to create a mental-health service that is more family-orientated, and we have made proposals to the Department as to how that might be achieved.

The report makes it clear that a number of professionals working in different settings made individual mistakes, which, when taken together, contributed to the deaths of this mother and her child. There was poor communication between the professionals themselves, and, importantly, there was very poor communication with the family on both sides — in one instance, there was no communication. Care planning for Mrs O’Neill was made on the basis of incomplete information and false assumptions. In the case of Lauren, it appears that a number of professionals, rather than individually invoking child protection procedures, left that to each other, and so the task that was everyone’s business became no one’s responsibility.

These failings were critically compounded by the failure of the notes to make the transition from Belfast to Derry. As a result, any written information about the threat to the child, and the opportunity to protect her, was lost — along with a real understanding of how profoundly ill Mrs O’Neill was. Therefore, the deaths of Mrs O’Neill and Lauren, as well as shining a light on human and professional errors, also highlight system failures, because no one was able to pick up on the situation. The quality assurance and sound governance systems did not work in this case.

Work is under way on a series of recommendations that are intended to improve policies and procedures. It is critically important that we improve those aspects of the system, because otherwise we will fail to underpin a safe and effective service. However, we need to modernise and make the service more family-orientated, otherwise the culture will not be there.

Boards and trusts are, therefore, committed to co-operating fully with the coroner in whatever approach he adopts to ensure a transparent public investigation into any further circumstances that we can elicit about that tragedy. The health and social services boards, and other health and social services bodies, are committed to doing everything that we can to avoid a repetition of that tragedy.

The Chairperson:
Thank you for the presentation. I should again like to offer my sympathies to the two families involved. This incident happed in my constituency, and when we heard the news it sent shivers down our spines, and the “what ifs” came into play. Sometimes it seems that, right across the United Kingdom, we have to have some dreadful tragedy before we look to tightening up the procedures. Sadly, it is now too late for Lauren and Mrs O’Neill. The one good thing that will come out of this affair is that the shortfalls will be examined and a more appropriate communication system put in place, particularly when there is a child living with someone who has mental-health issues. I am not here to conduct a witch-hunt. However, after the coroner’s report is published, there will be a great deal of interest as to whether there will be disciplinary proceedings and whether those recommendations are put into practice, otherwise we might, God forbid, see a similar tragedy.

Ms Ní Chuilín:
The report was sent to the board last year, and it was confidential. The Health Committee has been in existence for a year, and this is only now being brought before us. I have a concern about the recommendations of the report; the Committee has heard some detail about what those are and how they are going to be implemented. The way in which those recommendations are implemented will be crucial to the grief of the O’Neill and Gormley families. I am sure that they do not want to think that someone else will have to experience the same tragedy that they have gone through.

I understand that there are huge issues concerning next of kin, but I do not understand why — unless there was a court order saying that there are child protection issues concerning one of the parents — the other parent was not contacted, as he was the sole carer of the child when the mother was in hospital. There are a lot of other issues which no doubt will come out at the inquest, but I do not want to get into those, because it will sound like a witch-hunt. As for what is recommended in the report, how is that going to be implemented, and why did it take so long for this report to come to the Committee? What are the next steps in sharing this with the coroner? I am sure that the coroner’s office will have disclosure of all the documents.

Mr Burke:
That question is critical to the manner in which progress can be made in order to minimise the possibility of a recurrence.

Mr Hugh Connor (Eastern Health and Social Services Board):
You have raised about four points. The report was available in May 2007. It did not come into the public domain until March 2008. Why was that, and what was happening in the meantime? Well, as Dr Kilbane said, the report itself gave rise to questions for other agencies. There was a question for the Police Service concerning whether there would be a public prosecution, and a question for the coroner concerning how he would want to introduce his inquest. From the moment the board received the report, we shared it with both the Police Service and the coroner. They got it on the same day as we received it in confidence. The Police Service then told us, in November, that it had determined that there would not be a prosecution.

The coroner would not give us his advice until he had the advice of the police. Three weeks later, the coroner advised that he was content for us to release the report. That advice was given on 28 November, in the run-up to Christmas. In personal contact that I had with Mr O’Neill, he asked that the report not be released in the month of February, because it coincided with his child’s birthday. There was a preliminary coroner’s hearing in January, so we waited to see when the coroner’s inquest was going to take place, because if it was to take place quickly that would have a bearing on how the report would be released. It was then discovered that the coroner was not going to release the report until September, with the result that we then released it at the first available opportunity. We have not been sitting on our hands for the last 10 months. From the moment that the report was released, the board produced an action plan and put a process in place to look at how the recommendations were going to be implemented.

Ms Ní Chuilín:
I am glad to hear that, because if I were sent home with an acute physical illness, my mobility was severely restricted and I had a small child at home, I would like to think that someone would be wondering how I would feed myself and my child. I think that, because it was a mental illness, there was less attention given and fewer resources were available. It is not seen to be as acute a problem as physical immobility. There would certainly be child-protection issues if I could not feed my child. How are those procedures and protocols going to be tightened up?

Mr Connor:
One of the fundamental questions that you raise is important for the service, not just as regards the particular child who has died, and is, therefore, very visible because her case is so dramatic. The fact is that, from our perspective, thousands of children are living with parents who have mental-health and addiction problems, and they have to contend with that degree of poorer parenting. Obviously, many parents try to do their best despite their problems. We believe that it is fundamental to re-examine how the system operates, because the child-protection system and the mental-health system have to work together. They need to be more overarching in their attitudes.

One thing that emerges from the report is that, honestly, Lauren was invisible. Her mother was seen as someone who was mentally ill, and the health authorities tried to make her better. Lauren’s needs and, indeed, those of her father were not recognised. That is a fairly fundamental attitudinal-insistence issue that cannot necessarily be changed by policy and procedure. It needs to be examined further. There are already umpteen policies and procedures. We are not short of them.

Dr Kilbane:
You raised the issue of next of kin. We are well aware that Mr O’Neill is Lauren’s next of kin. You will have read the report and realised that there were other factors, and people were not keen to put that down. One of the important training issues in the recommendations is to never have a repeat of that — to be absolutely clear about who is the next of kin, to have that recorded, and to have the next of kin who is the carer informed about things. In fact, according to the record of Madeleine’s first hospital admission, Mr O’Neill was his daughter’s principal carer.

Mr Burke:
The other element of that is that, in childcare practice, one would normally expect multidisciplinary planning to take place in the form of family group conferencing, which would involve the family. The recommendation is quite clear that in mental-health cases where there are children, there should be family group conferencing, which involves the next of kin and extended family in supporting the patient and the children, to ensure that they are not exposed and that their needs are not ignored in the process, as happened in this case.

The Chairperson:
I noted that the family were offered no counselling. I find that totally incredible. The family lost a wife and daughter, yet no counselling was offered at the time. Has anything been done since to help those people, through talking therapy, for example, to come to terms with their loss?

Mr Burke:
Again, you have highlighted a difficult area. Some of the family have said that they do not wish any counselling, and that they are, in their words, “getting by”. Others, however, want counselling and have been encouraged to attend the counselling which is provided for relatives of people who have committed suicide. However, there is a serious difference with Madeleine’s family, because their sister is perceived not only to have committed suicide, but to have murdered her daughter as well.

To that end, the board has examined provision and has, through a worldwide suicide organisation, made contact with people who could pick up and provide one-to-one counselling in Northern Ireland for an individual member of the Gormley family who wants that support. We are in the process of negotiating the provision of that counselling and of getting it as quickly as possible. Indeed, I am aware that just before the publication of the report, the family raised that issue, and we have been pursuing it since then. We hope to have it in place quickly.

Mr Connor:
At the time, Mr O’Neill did not receive the counselling that he should have done. I have been the board’s representative dealing with Mr O’Neill from very the beginning, and I sought to offer him support and help. At that stage, he felt unable to avail himself of those services. However, he has recently indicated otherwise, and I have directed him to a number of counselling bodies which can help. I hope that he will take advantage of that; we will ensure that any support that he needs is provided for as long as is required.

Mr Easton:
It is difficult to know what to ask, and even more difficult to get my head around some of the issues. How long will it take to implement the recommendations? Are there any recommendations that patients with mental-health problems who have children be assessed to ascertain their capabilities of looking after those children when they are discharged from hospital? How do you plan to improve lines of communication among hospitals, GPs and counsellors to ensure that patients are well supervised and cared for after they are discharged?

Mr Burke:
As Dr Kilbane indicated, of the recommendations that fall to the Western Trust, 10 have been fully implemented, and 11 are in the process of being finalised. We expect that by the end of September, which is within the agreed timeline drawn up by the Department, the boards and the trusts, all the recommendations will be implemented.

That will enable us to ensure, through audit, that those recommendations are in place and actively making a difference. In turn, that will enable us to ensure that there is communication and that, on the question of the interface between mental health and childcare, there is a recognised manner in which such cases are dealt with to ensure that families are not left exposed in any way.

Mr Connor:
Dr Kilbane referred to a number of recommendations that are yet to be fully implemented. As she indicated, the reason for that is that work has been undertaken and new policies and procedures are out for consultation, need to be audited, or have generated training needs. It will probably be a further nine to 12 months before we can be assured that those policies and procedures are working.

In the meantime, new guidance has been issued to all the trusts that sets out new standards on the transfer between hospitals of patients and their records. We have also made counsellors aware that, if they are in a contract with the board, they are required to deliver on child-protection standards. We are designing training on that for those particular counsellors.

You asked about child assessment: it is important to reiterate that the child-protection policies and procedures have been in place for almost two decades, with amendments at regular intervals. In this particular situation, the important issue was that, as Dr Kilbane said, the child-protection policies, which were really everyone’s responsibility, became no one’s business to implement. We are obviously reminding people of those policies. A lot of work on child-protection training has been carried out in both trusts and boards. We have reorganised the training, and we are now absolutely clear that people will be aware of the policies. Nurses and doctors who have responsibility for child protection have been appointed in hospitals. However, a more fundamental issue is involved — how the risk to children and the processes are recognised in the context of childcare and mental-health services working together.

Mr Buchanan:
This damning report shows that health professionals across some of the trusts were neglectful. From a layman’s perspective, it is clear in the report that Madeleine was at high risk of committing suicide, and of harming not only herself but her child, too. It is clear from every page of the report that she had made a cry for help. However, that cry was not picked up on, and, as a result, there was devastation. The families involved are still completely devastated by what has happened.

Some of the questions that I intended to ask have been asked already. I want to know how the implementation of the recommendations will be monitored to ensure that they are working for the benefit of those in need. Are all the recommendations being implemented across all the trust areas? We hear so much about child protection, but obviously there has been a breakdown of communication when the child-protection procedures that Mr Connor said have been in place for decades are not being followed by trusts and professionals and so forth. How is that being addressed?

Mr Burke:
As regards the implementation of the recommendations, an improving mental-health services project team has been established, with directors in both the Eastern Board and the Western Board. As Mr Connor said, new policies and procedures are being developed and tested to ensure that they are robust and fit for purpose, and we are auditing that process. People are checking that the forms and the appropriate procedures at the point of admission are in place — although the number of transfers really is quite small. That will ensure that child-protection issues are being followed through on.

We are also looking at the training programmes — including multidisciplinary training programmes — that have been put in place, which will ensure better communication and raise awareness of child protection. Those programmes will ensure that staff know to whom to make referrals, what follow-up is necessary, and how to satisfy themselves that appropriate action has been taken. Carál asked how professionals involved in child protection can satisfy themselves that families are getting appropriate support and welfare; that is how it is being done.

Mr Michael Gormley (Western Health and Social Services Board):
I simply want to reassure Mr Buchanan that, of course, these recommendations go beyond two trusts. All the chief executives of all the trusts and boards are being asked to report on the implementation of the recommendations, and that work will be monitored.

Mr Connor:
The report has a 15-page literature review at the back, and it is very important and helpful — although I am not sure whether anyone has had the time to read it yet. Essentially, it looks at inquiries that have taken place in England and Wales. A question that arose repeatedly from those reviews concerned how the two systems operated together. We thought that policy and procedure, by themselves, would not necessarily lead to a change of culture. We suggested to the Department that the change was of such significance that it should be a matter of priority for trust chief executives. They have many priorities, but this should be a health and safety priority.

As the process of implementing these recommendations begins, we should assist the trust chief executives by appointing people to work with each of the trusts. They could consider how services evolve and develop, offer best practice, and — as Mr Burke said — try to introduce some other models of provision, such as family group conferencing. The Department agreed to that request, and that will be rolled out in the months ahead.

Dr Kilbane:
There are some very important issues about where child protection applies. This case was very unusual in that that child was not thought to be at risk because she was not on any child protection register. She came from a very happy, secure family. Even though her parents were not together, there was never an issue of them not both caring for her.

The mindset needs to shift in order to be much more aware of the child as part of the family, even in families where folk co-operate with their treatment. The literature shows that many people do not want to consider that this sort of thing can happen. A person’s intent to act in such a way is a mark of how profoundly ill they are. A woman has a very severe illness if she kills her child believing that she is protecting that child.

People think about child protection in the realms of children from families whose failure to cope with children is evident from an early stage. That mindset needs to change. We understand that that has been documented elsewhere, but we did not know that at the time. One of the important recommendations is that those sorts of research and findings should be put together.

Regrettably, it can be seen from reading newspapers that people on this island who have been depressed and ill have begun to take the lives of their children as well as their own. There have been a number of such instances. Perhaps there has been a fundamental change in society over the last few years, because it seems that something that was once extraordinarily rare has become more common.

Dr Deeny:
Thank you for your contribution, Dr Kilbane. That is exactly the point that I was going to make. You mentioned how rare those instances were. Just last week, in Wexford, four people died. Last year, I attended the funeral of the McElhill family in Omagh. In that incident, it appears that one family member took the lives of the others. In Wexford in 2007, there was another incident occurred where the parents had been to visit an undertaker. Worryingly, that type of incident is becoming more common. My sympathy goes out to the O’Neill family.

This was a very tragic and sad event, but it was not unexpected in my experience. I have worked in my practice for almost 22 years. It is the only practice in Northern Ireland that has patients in three different health board areas; the Eastern Board is the only exception. For years, I have said that one would think that we have four different countries when it comes to health provision, because communication has been so appalling.

I have admitted patients to one hospital and, within a month, if the patient is transferred to another hospital, the tests are repeated as there is no communication. That is a serious flaw in the system, and it is essential that we establish better lines of communication

I believe that it is the system that has failed. It is outdated and inadequate. I used to describe the process of communication between the boards as trying to pass the Great Wall of China because it is so difficult to do. God help us, but it has taken a terrible tragedy like this to highlight that issue; I hope that now it will be addressed.

The current system has let a number of people down. Maureen — was that her first name?

Ms Ní Chuilín:

Dr Deeny:
Madeline, sorry. Sometime people end up taking their own lives no matter what you do. However, perhaps she did not receive the care that she needed. The system certainly has let her daughter down — and her father for that matter.

I agree that this is not a time for carrying out a witch-hunt against individuals. I would like to see a Health Service that is open and transparent. If we start blaming individuals we will drive it underground. It is better to create a system were people can be upfront and admit to making mistakes. Only last week, for example, I prescribed 20 mg of a drug instead of 10 mg. Luckily, the chemist kept me right and I admitted that it was my fault. I am no angel.

I know that these things have to be done, but I have a thing about administration and bureaucracy. Reports, recommendations — it can go on and on for years. Things have to be done right and done now. Social services and child protection should inform the next of kin immediately. It could be the relevant health professional or an individual — I am thinking of the Wexford case where the undertakers were told that the parents were ordering coffins. They felt guilty afterwards. If anyone has a concern, they should contact their local health professional, who should get on the ball immediately if a child is perceived to be at risk or in need.

Secondly, it concerns me greatly that the notes from Knockbracken did not appear for two days —

Ms Ní Chuilín:
They did not appear at all.

Dr Kilbane:
They did not appear at all.

Mr Burke:
Not until after the deaths.

Ms Ní Chuilín:
They were found afterwards in a file somewhere in Gransha Hospital.

Dr Deeny:
They were discovered in a file two days after the deaths. It appears to me that —

The Chairperson:
Someone put them there.

Dr Deeny:
Yes. Somebody put them there.

You said that this girl was not at risk. However, I have to disagree with you on that point. If I had a child in my practice and the mother or the father told me that they were going to take the child with them, I would immediately come to the conclusion that that child was at risk.

There has to be immediate transfer of all medical information between trusts when the patient is transferred. If those two things can be done right away, then we will have already made great advances.

Dr Kilbane:
Let me clarify a few points. I may have expressed myself poorly when I spoke before. Madeleine O’Neill’s GP absolutely knew that Lauren was at risk. He conveyed that information, and we understand that the information was written prominently at the front of Madeleine’s medical notes. However, the problem occurred when the notes did not make the trip from one hospital to another and the issue did not come to the knowledge of the staff in Gransha Hospital. As a result, no one there knew what the risk to the child was.

The Chairperson:
Was there not an obligation on Gransha Hospital to telephone Knockbracken to ascertain where the notes where, before they started to treat the patient? I am not a medical person myself, but if a consultant is dealing with something as traumatic as someone with mental-health problems and has no notes to follow, surely the first thing to do is check with colleagues in another trust and find out what has happened? That is a reasonable expectation.

Dr Deeny:
Unfortunately, that is how the system operates. Time and time again, I have encountered situations when notes do not follow patients. If patients move from one board area to another, it is as though they are starting afresh in a new hospital. The system must be sorted out.

Dr Kilbane:
If the patient had been physically ill, a telephone call would have been made to enquire about the notes, the X-ray results, or the treatment that had been given. It is equally, if not more, important to enquire about notes when someone is mentally ill. However, we do not believe that any such telephone call was made. In the report, there is a suggestion of some thinking to the effect that requesting the notes would have breached confidentiality, but that is completely unacceptable. The transfer of notes is critical, and it must be timely. I do not know how patients can be treated without any notes.

Mr Connor:
I wish to reassure you that, following this case, new guidance has been issued clarifying the transfer of notes and patients. That is one thing that has come out of this incident, and we are seeking to audit the effectiveness of that guidance. In this case, there is a dispute about the notes, which will only become more apparent at the coroner’s inquest. It is impossible for us or the inquiry team to understand what happened to the notes.

You raised the issue of child protection and immediate referral. Unfortunately, a range of professionals did not do that, for a range of different reasons, although a policy and procedure has been in place for some time.

Dr Deeny:
That policy must now be mandatory. There is no point in waiting for the recommendations to be implemented.

Mr Connor:
That policy is obligatory, and it was obligatory before the incident happened.

Mr Gallagher:
I am a little confused about the notes. I understood from Dr Kilbane that the notes never left Knockbracken. Will you clarify that?

Dr Kilbane:
We do not know. There are two conflicting reports, which could not be reconciled by the inquiry team. Staff at Knockbracken Healthcare Park were clear that a copy of Madeleine’s notes was placed in an envelope and handed to a family member. That family member is equally clear that he did not receive those notes, and, therefore, he could not have handed them over. The report also states that there was an extensive investigation following the deaths to determine how the notes had been placed in the file, but, despite an intensive inquiry and interviews with all relevant staff, a satisfactory conclusion could not be reached. The independent inquiry panel held in-depth interviews, but it was unable to reach a conclusion. Therefore, the panel recognised that the matter would only finally be resolved through the coroner’s inquiry or through the PSNI.

Mr Gallagher:
Thank you for clarifying that. Unless I misheard, someone said a few moments ago that the notes never left. However, it was my understanding that there is still uncertainty about what happened to the notes. It may be that they were never sent, or that —

Mr Burke:
I think that Dr Deeny’s point was that notes were subsequently found in the community mental-health team’s Cityside office in Derry, and the question is how they got there. That is unclear, and the matter remains to be resolved.

Mr Gallagher:
Fair enough. Now that you have clarified that point for me, we can move on.

Mr Burke said that the system failed to take account of the needs of Lauren and her child, and Dr Kilbane referred to a report about an independent counsellor and a GP who saw Madeleine at some point in Derry —

Dr Kilbane:
No, that was in Belfast.

Mr Gallagher:
Thank you. Although there was no criticism of the performance of either of those two professionals, did you say that, as far as you could establish, they did not follow the procedures?

Dr Kilbane:
I did say that they did not follow the procedures.

Mr Gallagher:
OK. Given that so much difficult-to-follow information circulates in all walks of life — particularly in bodies such as yours — and files get bundled up and moved around, I have a bit of a thing about the recording of information. For example, a couple of weeks ago, a constituent — he has cancer, but there are some issues here that are transferable to other areas — told me that he had progressed through the system to the last appointment prior to surgery, and, having listened to the consultant explaining what is a serious matter, he realised that the consultant had not been talking about him. The problem was that the consultant had the wrong file. Consequently, when I hear about checking, I am interested in whether such checking is actually done.

Was there a procedure in place at Gransha such that, if the notes did arrive, somebody would have checked them? Furthermore, when the file was moved on to the Cityside community mental-health team, is there any record of somebody checking the file out of Gransha?

Mr Burke:
In fact, there is no record of those papers being received at Gransha, and there is confusion about to whom, if anyone, they were given, and a dilemma arose because, as no phone call was made to Belfast, staff there assumed that they had arrived, and there was a two-week period in which the people at Gransha were awaiting the papers’ arrival from Belfast.

Although an assessment was conducted at the point of admission, and ongoing assessments and treatment were provided for the patient in the hospital, other than the two telephone calls between the consultants who arranged the transfer, no one referred back to the source documents. That was, and still is, the dilemma.

Mrs Hanna:
The deaths of Madeleine and Lauren were a terrible tragedy, and their relatives have suffered also. As has been said, many of the systems were supposed to have been in place, but they were not working. We must have confidence that they will work in the future. There is always so much change in the Health Service, and more change is on the way, because the trusts and boards will change due to the review of public administration.

We hear about many of these issues all the time. We hear about poor, or no, communication with relatives. Such things are already happening. There is supposed to be obligatory transfer of notes already, but that is not happening. We must have the confidence that that will change. The system must be recorded, monitored and policed to ensure that it changes. Otherwise, we, and the public, will not be confident that it is changing. A wider culture change is required; everybody must change. There must be better communication — between trusts, boards or whatever — to ensure that people do not fall between the cracks.

The other big issue is that mental health is not as cut and dried as physical health, and it will require a huge breadth of services if it is to change. We have the Bamford Report’s recommendations, and we are hopeful that some aspects are changing, but a lot of change is required. Many more services, training and personnel will be required to make a difference, and I am not sure that that will happen.

Mr Burke:
That is more of a statement than a question. The last time I attended the Committee, I followed Professor McClelland, who provided a full presentation on the importance of investing in mental health and of recognising the breadth of services that are needed. In particular, if we are to ensure effective care in the community, we must have a sea change to ensure that we have the qualities and competence to deliver those services.

Much of what has been discussed today, as Mrs Hanna said, goes back to having confidence in the systems that are in place, so that — as a result of effective monitoring — we can satisfy the public that the service is effective and that, when transfers take place, when files are being changed or when patient information is being sent on, that work is done in a timely and confidential manner, and everybody must contribute.

It is not a matter of ticking boxes; it is a matter of changing attitudes and recognising that people need the information to treat the patient effectively and be part of family care. I totally take Mrs Hanna’s point that that will require a change of attitude, but it will also require investment, and people will have to work together. Much of that exists already, but we must ensure that people behave professionally and competently, based on the policies and procedures. Policies and procedures will not solve the problem. The problem will be solved by people delivering on those policies and working on the advice of other bodies.

Dr Kilbane:
Before we came here today, I asked Mr Connor to look at what the real-terms investment would be in the Eastern Board over the next three years. The additional investment is very modest; it will be about £2 million.

Mr Connor:
In the next three years, the Eastern Board will receive £10·5 million for mental-health services. However, that is juxtaposed with capitation moneys going out, allied to which is the question of cost efficiencies. In net figures, the Eastern Board will have additional revenue of between £2 million and £3 million for mental health.

Dr Kilbane:
Therefore, we must depend on major changes in attitude. However, we should do that anyway, because the report does not suggest that the problem was a lack of resources. The problem was about not having a joined-up service. It was about failure of communication; failure to assess the risk; and failure to take individual responsibility for the obligation to protect children.

Interestingly, last week, we had a visit from some folk from England who have recently reconstructed their mental-health services. They had to face the fact that they were unlikely to receive any additional funding — in fact, they had to take money out. We must question whether we are getting the absolute best from what has been invested. Not if we keep doing it this way — adding bits on around the edges. We have to throw it up in the air and reconstruct it.

There is a message there — although we may think that we have solved the problem, and sometimes we have, by adding, sometimes the system has to be reconstructed to make sure that the service is better delivered. The modernisation of attitudes and practices is a fundamental issue of this report.

The Chairperson:
Thank you for coming. We came early this morning so as to meet with some mothers and babies. We were aware that mental-health problems were involved. The fact is that we do not have a mother-and-baby unit in Northern Ireland. These women have long-term mental-health problems, but have their children with them. I am not questioning that, because they are being seen — albeit a very small nucleus of those women who present with ante- or post-natal depression.

Without dramatising the situation, these women could, God forbid, experience the same sort of problems. We must look very closely at working with mothers who present with mental-health problems before, during or following pregnancy, and those who continue on in a lifelong cycle of depression. It ill behoves any of us to think that Northern Ireland has got the right system. It is something that we are going to examine in more detail.

I have three main areas of concern. First, that the notes were not sent from Belfast to Gransha with the patient. Secondly, that no-one thought to follow up the lack of notes with the patient at Gransha — no-one thought to lift a telephone and ask for them to be sent. Thirdly, someone has deliberately brought a file from Belfast and placed it in Gransha. It was not spirited there; it must have been sent, put or deposited, however you care to phrase it. My concern is that somebody out there knows where that file was and why it did not turn up. They put it there, and they are still working within the system. There are still issues around that — we may never identify that person. The fact is that somebody moved the file from A to B after the event, when it was needed before the event. I wonder how that person or persons feel.

Ms Ní Chuilín:
It was blamed on Madeleine’s father.

The Chairperson:
Yes, the father was put under considerable stress and strain by the querying of his involvement in that situation. It is sad to think that somebody moved that file to the Gransha unit, and yet no-one will be held accountable for that strange event.

Obviously we have the inquest in September and the coroner’s report to follow through on, and we await that with interest. I hope that I can be given absolute confidence that if these people require counselling, they will get it. That needs to be done. What these people have gone through is because our system failed them — they did not fail us. Thank you all for your time.

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