Bones were being broken. Inmates were presenting with fractures. Over an 18-month period, there were 19 incidences of somebody suffering a fracture. Much of this was going on behind locked doors. In only one case was the occurrence of a fracture observed by a member of staff.
Inmates of institutions suffering broken bones is something that might fit into the horrors revealed in the Ryan report. In this case, however, it's not from the distant past, and does not involve the abuse of children at the hands of religious. It concerns the treatment of residents in the care of a state-run hospital, as outlined by a recently published report by the Mental Health Commission (MHC).
While much breast beating has taken place since Ryan was published, it has largely been focused on the past. How could society have let that happen? Why didn't somebody shout stop?
Today, there is an ongoing scandal in the treatment of those suffering from mental health difficulties. In the case of children, this involves incarcerating those in need of medical care. One week before Ryan was published, the Inspector of Mental Health Service published his annual report for 2008. Included in it was a section on the care of children.
"Over 200 children have been admitted to approved centres for adults in 2008," wrote Dr Patrick Devitt. "This practice is inexcusable, counter-therapeutic and almost purely custodial."
At a time when so much is focused on purging the sins of the past, it serves as a timely reminder of the deficiencies of the present.
The report into fractures suffered by patients in care illustrates one element of the scandal. Between July 2002 and January 2004, there were 19 cases of patients in St Luke's Psychiatric Hospital in Clonmel suffering fractures. An investigation in September 2004 was told by a risk manager that she was "concerned that the injuries may have been non-accidental or due to a poor standard of care". Non-accidental injuries implies that the injured patients were assaulted. One of the wards in the hospital was permanently locked. There was found to be chronic understaffing in the hospital.
"Residents' accounts indicated that assault by fellow residents was the cause of some injuries," the MHC report stated.
A meeting of senior medical staff and managers to deliberate on the inquiry's findings did not take place until the following July, nearly a year after the investigation.
The meeting, as outlined in the MHC report, was a shambolic affair. Psychiatrists in attendance were concerned that they hadn't been told previously that residents may have suffered non-accidental injuries. Others only had access to the investigation's findings just before the meeting. No minutes were taken. "Many of those attending were unclear about the authority of the meeting."
In early 2006, another opinion was sought on the nature of the injuries suffered by the patients. The following October, an orthopaedic surgeon concluded there wasn't sufficient evidence suggesting that the fractures were "non-accidental". Ultimately, it was deemed inconclusive as to whether or not residents in the hospital were being assaulted.
All of this was going on in a building that sounds like something out of a darker age. The inspector's 2006 report noted of various wards in St Luke's: "The floors were uneven and slippy. This was not safe for a patient group at high risk of falling… a large hole in the flooring in the 'TV room' presented a trip hazard. Some of the floor tiles were beginning to lift at the edges and were becoming trip hazards."
The MHC report concluded: "There has been little further investigation and several of the 2004 report's recommendations had not been addressed. The incidence of fractures has not changed substantially but comparison with other hospitals is not possible at present. The inquiry team identified a number of potential risks to residents and concluded that the safety and welfare of residents has not been given sufficient priority."
There is nothing to suggest that St Luke's in Clonmel was any worse than other psychiatric hospitals around the country. Annually, the inspector's report is a litany of conditions that would not be tolerated in the rest of society.
Earlier this year, Brendan Drumm, the head of the HSE, said St Luke's would close next year. And therein lies another scandal.
Moving residents of psychiatric hospitals out to the community to be cared for is deemed best practice. In the 2006 mental health blueprint 'A Vision for Change' – launched with much fanfare – there was a commitment that money garnered from the sale of these buildings would be ringfenced for mental health.
In February 2008, junior health minister Jimmy Devins confirmed this policy to the Dáil, adding that: "Mary Harney has also made it clear to the HSE, in the context of their Service Plan for 2008, that there can be no question of diverting capital or development funds (from mental health) to meet expenditure pressures arising in relation to core services."
Not so, according to those working in the service. A report by the Irish Psychiatric Association last year concluded: "Lands have been sold or given away at significant under-valuations or at no cost to the receiver… the trend apparent to the authors suggests that psychiatric services represent an easy target by planners and managers to appropriate assets to meet shortfalls in current and capital expenditures of general health services."
The report, entitled 'The Lie Of The Land', detailed all the buildings that had been disposed of. Included was St Canice's Hospital in Kilkenny, which has since become HQ for the HSE South.
"In the early days of this transition, the high level re-fit of the top floor administrative section was very unfavourably contrasted with the poor physical environment in the middle and ground floors that continued to be occupied by patients," the authors wrote.
Only the best for those administering the service, only the worst of conditions for those using it. All the indications are that within the HSE, assets emanating from the mental health sector are being stripped to plug holes elsewhere in the system.
Starving any sector of resources is one thing, but within mental health it brings further complications. If the appropriate personnel are not appointed to operate the system, dependence on drugs is increased, irrespective of how inappropriate that might be.
Fifteen years ago, Caroline McGuigan found herself experiencing anxiety and panic attacks, which began to develop into something more serious. She went to her GP and was prescribed anti-depressant drugs. She advanced from there to contact with the mental health service.
"Over three months I went from zero to 16 tablets a day," she recalls. The drugs didn't work as far as the roots of her condition were concerned. A few years into it, she attempted suicide.
"It took me six years to get off the drugs," she says. "I eventually got one-to-one therapy and that's what saved me. Medication alone wasn't enough."
McGuigan's experience led her to set up Suicide or Survive in Arklow, Co Wicklow, which offers an education and therapeutic programme for those in need of it. SoS is not funded by the HSE despite being an example of what can be achieved within the community model. Through her organisation's clients, she hears what the service is like these days. Not a lot appears to have changed.
"To be fair, it often depends on what part of the country you live in," she says. "But it still seems to be medication as the only option the majority of the time. Medication alone is not what people need. Medication is still definitely overused."
Consultant psychiatrist Siobhan Barry agrees that drugs are playing a larger role than may be necessary. "In the absence of having sufficient numbers of people to deliver more comprehensive treatment programmes, there is certainly an over-reliance on drugs."
Providing the appropriate personnel is a key plank of Vision For Change, but like much in the mental health sector, the policy makes all the right noises in the right places, but then disappears.
The latest review of Vision For Change from the professionals in the system, written by Barry and her colleague Dr Patrice Murphy, highlights the abject failure to deliver a service. "The commitment made in late 2005 to establish 18 additional multidisciplinary adult psychiatric teams nationally in 2006 (360 new posts) has not been realised nor is there any sense that it would happen at any reasonable future time point." The authors point out that at the current rate of recruitment it would take 40 years to engage sufficient staff to fulfil basic requirements.
The failure to properly staff a community-based service is having other effects. For over 30 years, it has been regarded as best practice to treat patients in the community rather than behind the high walls of institutions. Now, according to Dr Dermot Walsh of the Health Research Board, patients are staying longer in hospitals, rather than face the uncertainly outside.
"Over the last few years the rate of discharge of long-stay patients has decreased," he said. "While we don't know for definite, that appears to be connected to the failure to provide an adequate community-based service."
At the tail end of a decade of plenty, mental health services are in danger of slipping further back into the past rather than being brought up to a standard becoming of an allegedly civilised country. All services are under pressure in the current environment, but mental health has been labouring in the wilderness longer than any other. The nature of the illness, the stigma that persists in some quarters, and the understandable absence of a coherent voice from those who suffer, all contribute to the manner in which it has been ignored.
As the American author and legal academic Elyn Saks wrote in her autobiography: "When you get cancer they send you flowers, but not when you get schizophrenia."