Kerry mental health unit 'high risk' in medication management and physical restraint practices

An unannounced four-day inspection in July 2025 assessed the Sliabh Mis Mental Health Admission Unit at University Hospital Kerry. The approved centre had three wards and accommodation for 34 residents, achieving 88 per cent compliance with the Rules, Regulations, and Codes of Practice. Two high-risk non-compliances were identified, alongside medication management shortcomings. Missing records for administered medicines were found, with incomplete allergy information and failures in monitoring high-dose antipsychotic treatment. One patient was not identified as receiving HDAT, and no pharmacist reviews were in place, while the medication policy did not address HDAT prescribing. Physical restraint incidents were also reviewed, with non-compliance linked to improper incident handling and policy gaps on staff training for safety monitoring. Non-compliance increased from three to six since 2024, with improvement works underway but ongoing issues including pharmacist review and omissions in the resident register.

"The inspection found shortcomings in medication management practices, including missing records for administered medicines. This also included incomplete allergy information and failures relating to the monitoring of high-dose antipsychotic treatment, with one patient not identified as receiving HDAT and no pharmacist reviews in place. The centre's medication policy also failed to address high-dose antipsychotic prescribing."

"On the use of physical restraint, three episodes were reviewed. The centre was found to be non-compliant with the code of practice due to improper handling of restraint incidents, where restraints were not ended by the designated lead staff member in two cases, as well as gaps in policy, including a lack of procedures for staff training on monitoring patient safety during and after restraint."

"Not all staff had completed mandatory training in the required areas; however, a training schedule was in place to address these deficits. In terms of prescribing, storing, and administering medicines, the inspection found shortcomings in medication management practices, including missing records for administered medicines."

"The report found that non-compliance levels doubled from three to six since 2024, with two repeat areas of concern identified. Ongoing improvement works were underway at the premises and seclusion area, while issues remained around the lack of a pharmacist to review residents on high-dose antipsychotics and omissions in the resident register."

Read at Irish Independent