There's clear evidence that 'significant harm' was caused to 46 children and young people as a result of the care they received at South Kerry Child and Adolescent Mental Health, a review has found.
The HSE has today published the report into the care received by young people at the site between July 2016 and April 2021, and the health service has apologised to all children and families impacted by the problems identified.
A review, ordered amid concerns around the care provided at the site, looked at 1,300 files from the service.
It has found that the care received by 240 young people "did not meet the standards which it should have".
Some 227 of those cases were associated with care provided by one junior doctor, while 13 other children were "found to have been unnecessarily exposed to a risk of harm under the care of other doctors in the service".
"There was clear evidence of significant harm" caused to 46 children - including issues such as weight gain, sedation, elevated blood pressure and galactorroea (the production of breast milk).
There were no cases of 'extreme or catastrophic' harm to patients.
Key problems identified included “unreliable diagnoses, inappropriate prescriptions and poor monitoring of treatment and potential adverse effects”.
That included diagnoses of ADHD being made without the right amount of information from the children's teachers.
Checks around any unwanted effects of medications (such as changes to pulse or blood pressure) did not always happen, while necessary blood tests weren't always done.
Problems such as the lack of a consultant clinical lead for a team at the site were among the key contributory factors identified, while staff also faced a "disproportionate workload and caseload distribution".
Concerns around the doctor in question were first reported in 2018, but the review team found "no proof" that the concerns were addressed after they were first reported.
Dr Sean Maskey, author of the report, has now put forward 35 recommendations for the Kerry service to implement.
Responding to the report, Michael Fitzgerald - Chief Officer of Cork Kerry Community Healthcare - said: “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.”
Taoiseach Micheál Martin has confirmed there will be a nationwide audit of Child and Adolescent Mental Health Services (CAMHS) services following the "unacceptable" situation in Kerry.
He said: "A full nationwide audit of compliances with CAMHS operational guidelines by all CAMHS teams will happen.
"Furthermore, a prescribing audit will be conducted in each of the 72 CAMHS teams nationally, and the Government are going to look at any further measures that are required then."
