I welcome everyone to the meeting. I have apologies from Deputy Smith and Senator McCarthy.

I will read a formal note on privilege. I remind members of the constitutional requirement that they must be physically present within the confines of the place where Parliament has chosen to sit, namely, Leinster House, in order to participate in public meetings. I will not permit members to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting.

On behalf of the committee, I extend a very warm welcome to Mr. Joe Loughnane and Professor Louise Doyle. I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards references witnesses may make to other persons in their evidence. The evidence of witnesses physically present or those who give evidence from within the parliamentary precincts is protected, pursuant to both the Constitution and statute, by absolute privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks and it is imperative that they comply with any such direction. Before we hear from our witnesses, I propose to publish their opening statements on the committee's website. Is that agreed? Agreed.

We are engaging with Mr. Loughnane and Professor Doyle regarding a person who presents as suicidal not having to go through an accident and emergency department. We will consider the establishment of 24-7 crisis care centres. I am pleased to welcome our witnesses here this evening. Before we start, I thank them most sincerely for the time effort they have put into this campaign. We have some members joining online, while others are speaking in the Chamber and will appear shortly. There might be a bit of coming and going. I am sure the witnesses are well used to that.

I call Mr. Loughnane to begin his opening statement.

I wish members of the committee a good evening and I thank them for this opportunity to speak about my brother Adam and the campaign we have started since his death. I wish I were not here. I wish instead that I was reading some long, whimsical text from Adam sent into the family group chat. There is no escaping the reality of losing a loved one to suicide, however. It is a pain you learn to live around. It is a pain that has inspired my family to advocate for more appropriate settings for people experiencing a mental health crisis. The revolving door nature of endless visits to emergency departments is forcing our loved ones to end their lives.

In Adam’s memory, we have been campaigning for the establishment of mental health accident and emergency departments, a campaign which has the support of over 21,000 people through a petition, as well as support from the Mental Health Commission, Mental Health Reform, the Irish College of Psychiatrists, the Irish Patients Association, mental health advocates like Niall Breslin and hundreds of elected TDs and councillors across the country. We have also received international support and research assistance from people involved in the establishment of mental health accident and emergency departments through the NHS in the UK and from those creating EmPATH units on hospital campuses across the US.

What we are asking for has been demanded for the best part of a decade. In 2017, over 12,000 people signed a mental health petition presented to the then Minister of State, Deputy Helen McEntee, calling for 24-7 crisis, community-based mental health services. In 2019, a Mental Health Reform report on a national consultation with mental health service users showed widespread support for alternatives to accident and emergency departments for people in a mental health crisis. In 2020, a motion calling for a separate emergency facility for mental health patients at Limerick hospital was unanimously passed by the council. In 2021, Ms Colette Douglas called for dedicated mental health accident and emergency departments following the tragic death of her son, Rob.

Adam was the next brother down from me. He was an academically gifted young man and one of the kindest, most gentle souls I will ever meet. Years of physical and psychological violence broke his spirit and he found himself, in the later years of his life, in and out of the emergency department due to suicidal ideation. Adam presented at the emergency department of University Hospital Galway, UHG, on the afternoon of Tuesday, 11 February 2025. He had woken up that morning feeling numb. He contacted his mental health support worker, who made the decision to contact UHG. He packed an overnight bag in the belief he would be at the hospital for a few days. Once he was at the hospital, he told staff numerous times that he wanted to end his life. He was seen by a triage nurse and was then told to wait for a liaison psychiatry team. He waited over an hour and a half before walking out and ending his life in the River Corrib.

Our campaign has continuously pointed out that Adam's death was not the fault of any one staff member; the system failed him. The medical professionals who tried to help Adam are overworked, underpaid and understaffed. They can only do so much with the facilities provided to them. Most emergency departments in the country have not been updated in over 20 years, as referenced by Mr. Paul Mulholland in an article in the Medical Independent one month before Adam passed. I refer specifically to a meeting of the HSE West and North-West regional forum in which a councillor said there should be more staff with specific mental health training in the emergency department if that is where patients had to go. The HSE response was that this level of training was not in place at that moment. How can the HSE expect someone in a mental health crisis to present to the general emergency department even though there is no mental health training for the staff working there? This creates a significant barrier in the mental health crisis journey as someone who is suicidal will always go to their local hospital as their first port of call. It is at this point in their journey that an option needs to be presented to them, whereby they can attend a mental health accident and emergency department on the hospital campus instead of sitting in the overcrowded emergency department.

A report by the Mental Health Commission on the delivery of mental health services in emergency departments found substantial variations in the services provided at all emergency departments. It said steps need to be taken to enhance access to care, especially for those presenting out of hours. A University Hospital Galway survey respondent commented that access to the consultant liaison psychiatry team at UHG is limited and, therefore, the emergency department staff are dependent on an out-of-hours service.

Bed capacity is challenged in the acute adult mental health unit. Patients with mental health difficulty requiring admission wait for prolonged times in the emergency department. Dr. Lorcan Martin, president of the College of Psychiatrists of Ireland said that, for those in crisis, emergency departments need a separate section, with a mental health professional, where somebody can be quietly and promptly seen and triaged and moved away from the main hubbub. They need an environment that is not over-stimulated or competing with everything else. Somewhere just curtained off in emergency department is not sufficient. Dr. Martin suggested separate psychiatric emergency departments, possibly located in less busy smaller hospitals.

On May 13 2025, the Royal College of Nursing, RCN, in the UK revealed how thousands of people in a mental health crisis were waiting for days in an accident and emergency department. Eleven days later, the NHS, which has been found lagging for years in this area, announced it would open a network of mental health accident and emergency departments across England.

Patients can walk in or be referred to the units by GPs or the police. They are set to be open 24-7 and designed to provide a calm and welcoming environment in contrast to the noise and chaos of major hospitals.

Just last month it was revealed that hundreds of people died by suspected suicide shortly after being in contact with healthcare services in Ireland. Documents obtained by The Journal Investigates show that 449 suspected suicides were recorded on the HSE’s internal reporting system between 2022 and 2024. The incidents are logged by staff when a death occurs within three weeks of contact with a patient with mental health difficulties. The figures are not publicly reported, and do not appear in official suicide figures until after a coroner’s inquest officially determines a cause of death, which can take place months or even years later. The Journal Investigates has found that Ireland’s mental health system routinely funnels those in suicidal crisis through busy accident and emergency departments, with little capacity to track or protect them after they leave.

Every day, another overcrowded accident and emergency department makes the news. As usual, the advice is to look somewhere else before presenting at the accident and emergency department and, therefore, let us take that advice from the perspective of people in a mental health crisis or with suicidal ideation. If they go to their local pharmacist and tell staff they want to end their life, they will be told to go to the overcrowded emergency department. If they go to their GP and tell them they want to end their life, they will be immediately referred to the overcrowded emergency department. If they go to the local injury unit and tell staff they want to end their life, they will be sent to the overcrowded emergency department. It is the same for a private GP out-of-hours service, they will be brought to the overcrowded emergency department.

I will now talk specifically about Adam and what happened with his death. The HSE external review has recently concluded that they cannot determine why Adam walked out of the emergency department. They arrived at this conclusion despite a catalogue of errors on their part, as identified in the review, which I will outline here. I outline these errors as they provide the most tragic evidence as to why emergency departments are entirely inappropriate settings for someone in suicidal distress. They know that Adam contacted a mental health social worker and the community mental health team three to four days prior to his death. On the day of his death, a member of the clerical staff advised that he attend the emergency department despite the waiting time between presentation and triage being 50 to 60 minutes and the fact that there were over 100 patients in the emergency department during the time Adam was there. Adam was triaged as category 2, very urgent, and this decision was based on Adam's presentation as well as his previous history. Adam was accompanied to the general waiting area as the two rooms that would usually be used for interviewing patients with mental health issues were already in use. In any given day there will be at least three or four suicidal presentations to the emergency department. The psychiatry liaison team members were already in the emergency department assessing another patient. They were also short-staffed that day due to one member of staff being off sick, one member on annual leave and one post remaining unfilled. There was no capacity within the team to respond in a timely manner. Adam was returned to the emergency department waiting room at 2.40 p.m. On review of available CCTV footage, there is no evidence of anyone other than one nurse communicating with Adam, checking in or reassuring him, despite having been triaged as requiring urgent review. Adam's absence from the emergency department remained undiscovered and only became apparent when he had been brought back into the emergency department by ambulance. The nursing staff tried unsuccessfully to enter his details on their registration system and found the information already logged. He had never been un-logged. He had just walked out.

I will now turn to the important issue of costs. In the 2025 budget, €1.48 billion out of €25.8 billion, which is 5.7%, was spent on mental health. In the 2026 budget, €1.6 billion out of €27.4 billion, or 5.8%, will be spent on mental health. Once again, less than 6% of the health budget has been allocated to mental health this year. This is well below the 10% recommended by Sláintecare and less than half of the 12% recommended by the World Health Organization. It cost £4 million of an investment to establish a mental health accident and emergency department in Middlesex in the UK. That is around €4.6 million. Using the NHS figures, establishing a mental health emergency department in each of the 26 counties would cost less than €120 million. This is less than 8% of the mental health budget and less than 0.5% of the overall health budget. To pilot a mental health emergency department on the University Hospital Galway campus would probably cost less than 0.02% of the overall health budget. Granted that this initial investment is for buildings and staff and there will be a need for continued investment for equipment and further staff, but this proves that what we are asking for is not only entirely realistic, it would make no real impact in any way on the health budget.

I will now focus on media reports surrounding the opening of minor injury units or urgent care centres. It was reported recently that the opening of a minor injury unit in Athlone was to be delayed by several months. The following was said by a hospital manager in relation to the anticipated benefits of the unit: "By treating minor injuries locally, we can ease the burden on our emergency departments and ensure patients receive the right care, in the right place, at the right time." Separately, it was also reported that HSE South West reminded the public in Kerry about a new specialist mental health hub operating as an alternative to the emergency department for those experiencing a mental health crisis. There is only one catch: you cannot just walk into this hub, you have to be referred by your GP or clinician. A dedicated mental health accident and emergency department would operate in a similar way to the minor injury unit in Athlone, but would not require a referral, unlike the specialist mental health hub in Kerry. We are seeing a network of mental health accident and emergency departments being opened across England for those in a mental health crisis and we are now seeing urgent care centres being opened for those presenting with non-critical physical issues. In another article, patients with cancer in Limerick were notified about a helpline that will help them to bypass the emergency department during the busy winter period. If they need to see a nurse or a doctor in person, they can go to a specific ward and avoid the emergency department. This is obviously a good thing and long may it last. Up to 10,000 people die by cancer in Ireland every year but it proves that an alternative to the accident and emergency department for a specific type of illness or injury is already in operation. Why is this not being done for people in suicidal distress or those experiencing a mental health crisis? The HSE could give out a helpline number that connects those affected with a psychiatrist or psychologist in the inpatient mental health unit. If they needed to come in, they could make those same inpatient mental health units operate on a walk-in basis for the Christmas period.

The emergency department in Portlaoise has recently been extended and the opening date was sped up to make it operational to deal with the increase in flu cases. This is positive news that should be happening but why can this not be done for mental health? Experts in the treatment of strokes have called for more mobile stroke units after a study they conducted found the units reduced admissions to emergency departments by 86%. Once again, this proves that an alternative to accident and emergency departments for leading illnesses provides the best health outcomes for everyone involved.

Crisis response centres, psychiatric emergency departments, EmPATH units and urgent mental health care centres are all variations of mental health accident and emergency departments found across the world. They are all public, all 24-7 and all with no referral required. Canada is leading the way in providing separate crisis care facilities for people experiencing a mental health emergency. A psychiatric emergency zone in the Michael Garron Hospital, Toronto East Health Network, and a mental health emergency zone in Hôpital Montfort are two leading examples. In the UK, ten NHS Trusts have launched separate units for mental health crises, some on sites alongside existing accident and emergency units, but the scheme is expected to be expanded nationally to dozens of locations as part of the ten-year NHS plan. Two examples are the Central and North West London NHS Foundation Trust mental health crisis assessment service and the Essex Partnership Trust mental health urgent care department. Both are 24-7 walk-in emergency departments dedicated to people presenting in a mental health crisis. Both services have already won various NHS awards despite only being in existence for a couple of years. They exist on hospital grounds where a general accident and emergency department is also in operation. Research is showing in both areas that pressure on the general accident and emergency departments has started to ease off.

If Adam had been advised to attend a more appropriate setting for someone experiencing a mental health crisis, I genuinely believe he would still be here today. He had done everything right, but ultimately he was failed when he needed help the most. Adam's death has shone a light on an experience shared by thousands of families across this country. People in suicidal stress are being ignored and stigmatised by inappropriate healthcare environments providing inadequate care. This has to be the line in the sand. We have the funding, the buildings and the people to create separate, dedicated emergency departments for patients experiencing a mental health crisis.

I thank Mr. Loughnane.

I thank the committee for the opportunity to speak. I am a professor in mental health nursing and head of mental health nursing at Trinity College Dublin. My research is focused on suicide and self-harm, and I have over 20 years’ experience in this area. I welcome the opportunity to present the key findings of two recent studies focusing on the experiences of service users and their families following presentation to emergency departments with suicidal behaviour. These studies have been funded by the 3Ts charity and the Irish Research Council.

The first study focusing on service users sought to understand what the experiences are for a person in acute psychological distress when presenting to an emergency department and how our systems of care respond to them. Although policy and clinical guidance recognise the emergency department as a key point of contact for individuals in crisis, the lived experience of patients has been largely absent from the national conversation. Our research sought to address this. We undertook a large qualitative study that looked at the experiences service users had when presenting to the emergency department with self-harm, attempted suicide or suicidal ideation. We conducted in-depth interviews with 50 people from across the country, interviewing 39 women and 11 men ranging in age from 19 to 68 who attended 21 of the 26 emergency departments in Ireland.

Just under half presented with suicidal ideation alone, the remainder attended after an act of self-harm, including overdose or self-cutting. The pathways to the emergency department varied, and included GP referral, self-referral and ambulance attendance, but a common thread was the high level of distress and the reliance on the ED as the primary, and often only, available option at that time. As one participant noted:

I knew I was in trouble, you know. I needed help quickly or something bad was going to happen. I couldn't keep myself safe. Or I felt I couldn't anyway. So I did what she [the GP] suggested and went to A and E.

Participants' experiences of assessment and treatment in the emergency department were largely negative. It was not viewed as a conducive environment to engage in any kind of therapeutic communication, and staff were perceived as being hurried and under time constraints. Participants described mental health assessments in the ED as formulaic, rushed, and lacking depth. Many felt they were delivered as tick-box exercises rather than meaningful clinical engagements. Non-mental health ED staff were often perceived as uncomfortable discussing suicidal thoughts or self-harm, leading to interactions that felt mechanical or dismissive. In contrast, positive experiences emerged when participants were assessed by mental health staff including clinical nurse specialists in self-harm or psychiatric non-consultant hospital doctors, NCHDs. These clinicians were recognised for their calm approach, their expertise, and the time they took to truly listen, enabling patients to speak openly about their distress.

For individuals with self-harm injuries, the focus was frequently on physical treatment alone, with limited attention to the psychological crisis that led to the behaviour. Those presenting with suicidal thoughts, but no physical injury frequently felt there was "nothing that could be done" for them in the ED and that they did not belong there. One participant noted:

Other people are actually [physically] sick, and you don't think you're sick. And you're like "I shouldn't be here, I don't need to be here, why the hell am I here with all these people?" It ruminates in your mind constantly. And the longer you're there the more you go over and over and over that in your mind. And I think that adds to the fact that you just want to get up and walk out.

Long waiting times were almost universally reported and, while expected, they were extremely distressing. Noisy, crowded waiting rooms heightened anxiety and worsened emotional turmoil. People often waited for hours while feeling vulnerable, ashamed, or frightened. Many expressed a desire to leave before being seen, especially those who attended alone.

Privacy emerged as a significant issue. Only a small number of participants were assessed in a private room. Most described being interviewed in open or semi-open spaces where they felt overheard or exposed, leading to reluctance to disclose sensitive information. As one participant noted:

There's the privacy of it as well. I mean, if you break your leg, it's not really a personal, private upsetting nature. But if you're going there and you want to die ... you're at your rawest of your raw at that point.

Participants also spoke of feeling "othered" or stigmatised, set apart from those with visible physical health issues. Some described "special observation areas" that felt more like containment spaces than supportive environments. The consequences of negative experiences in the ED were profound. Many said their experiences exacerbated feelings of shame, worthlessness, and self-blame. Some described being retraumatised by judgmental or dismissive attitudes from staff. Critically, several participants stated they would not return to the ED again if they became suicidal, revealing a dangerous gap in crisis response.

Despite the challenges, nearly all participants could identify at least one positive interaction. These were often simple but meaningful: a kind receptionist, a porter who offered reassurance, ambulance personnel who stayed with them, or an ED nurse who spoke gently and without judgment. Calm, compassionate engagement rather than complex intervention was the strongest predictor of a positive experience. Privacy, timely assessment and knowledgeable mental health staff also significantly improved ED experiences.

Family members can be an important source of support for people presenting to the ED in mental distress and suicidal crisis. However, this study found that family members were frequently left unsupported, with little guidance on how to keep their loved one safe at home. This finding led to the development of our follow-up study. This was a national study exploring the experiences and support needs of family members and supporting adults who accompany a person to an emergency department following self-harm, suicidal ideation or a suicide attempt. This research captured the responses of 239 participants from across Ireland in an open-ended survey, offering one of the most comprehensive insights to date into how families experience our emergency mental health response. Some 68% of participants reported that the person had received an assessment from a mental health clinician with 67% reporting that this assessment took place in a private space; 52% of family members reported being included in that assessment. However, only 10% of participants reported that their family member received a safety plan despite this being a core component of the national clinical programme for self-harm and suicide-related ideation, NCPSHI.

When it came to the issue of treatment provision to the patient in the emergency department the experiences of family members, like the service users in study 1, were generally negative. While some staff were described as caring, compassionate and doing their best in overstretched conditions, more than half of participants did not believe staff had the skills or confidence to respond adequately to people in suicidal crisis. Some reported judgmental or dismissive attitudes, especially toward patients who presented to the ED more than once or those affected by alcohol or drug use. Comments such as "You're back again?" or "Why would you do this to yourself?" left people feeling ashamed and reluctant to remain in the emergency department, with obvious implications for safety. As in study 1, there was a focus on attending to physical care, which was viewed as expertly done, but little focus on the mental health difficulties that underpinned the presentation. As one participant noted:

The main focus was on the physical health, but when she had come around and was physically better there was no mention of the fact that it was a suicide attempt. It was like they just wanted her out.

Participants described EDs as overcrowded, noisy, chaotic and frightening environments that resulted in heightened distress. For children and adolescents, the reported experiences were particularly concerning with long waits and a lack of age-appropriate spaces with parents trying, sometimes in vain, to convince the young person to stay for assessment and treatment.

Families consistently expressed a need for clear information, including warning signs, crisis contacts, what to do in an emergency and how to keep the person safe at home. In this study, over 70% received no such information. It is important to document that positive experiences were also identified by some participants and where these occurred, they focused around expertly delivered physical care, compassionate and empathetic interpersonal interactions and being listened to and taken seriously.

Participants provided in-depth responses on what could be done to improve the care in the ED for the patient and the person accompanying them. Treatment-specific recommendations included improved assessments, more patient-centred care, inclusion of supporting adults in assessment and patient management and the provision of relevant information to accompanying adults. Participants also identified the need for a more conducive environment for people in acute mental distress, which was eloquently summed up by one participant who said:

With mental illness my brother looked at others in the waiting room and felt like he didn't matter as others were going in before him as he was seen as low priority. This reinforced his feelings that he was useless, unwanted, unloved and had no place in this world.

Some recommendations from both studies consolidated underscore the need for systemic improvements in crisis mental health provision, both within and outside the ED. The following service recommendations were made. There should be an increase in the range of unscheduled and crisis mental health services in the community for those presenting with self-harm, suicide-related ideation and suicide attempt who do not require medical intervention in the ED, or following that intervention in the ED. Both service users and accompanying family members repeatedly called for alternatives to the emergency department, or subunits of the emergency department, providing safe, calm, specialised mental health crisis centres staffed by mental health professionals. The capacity of community mental health teams to respond to urgent referrals of new and existing patients should be increased. There should be targeted investment in child and adolescent mental health services, particularly for emergency presentation to prevent children and adolescents being held for long periods in adult ED environments.

The emergency department will always be part of the mental health crisis landscape but it should not be the only door and, crucially, when people do walk through that door, the experience must be safe, compassionate, and responsive. For some in our studies, this was the experience, especially when seen by specialist mental health staff including those working as part of the national clinical programme for self-harm and suicide-related ideation. However, for many, the healthcare responses in the emergency department were suboptimal. Our studies show that people in suicidal crisis, and their supporting families, are not asking for complex interventions in an emergency setting. They are asking to be treated with dignity, listened to with patience, and supported with care in an appropriate environment.

I thank both of witnesses very much for their evidence.

I will open it now to questions from the committee. I absolutely agree with Mr. Loughnane that he should not have to be here. We should not know his name and we should not know Adam's name. However, we are very grateful that he is here and that he has shared what is a very painful experience. He has shared that with us and it will guide us.

I thank our two speakers. I reiterate what the Chair said. It is not easy and Mr. Loughnane should not be here. Actually, I should not be here. That is my background and this is what got me into politics, to do exactly what Mr. Loughnane is trying to do here in this committee, which is to change things. I sat on the committees which produced the Sláintecare report and the future of mental health care report, as did others. I will let them speak for themselves. I heard what Mr. Loughnane said about the revolving door. That door has only been oiled. Nothing has changed in that. That is the only cosmetic dressing that has been done - just keep that door turning. I was on an RTÉ show a long time ago and they were going through numbers. As I was going out to the studios, I had a conversation with the taxi driver, who worked for a coroner. I learned more off him in ten minutes about how suicide can be reported. Whether it is filicide, drownings and overdoses, these can all be cosmetically dressed up. A particular case where a mum killed the two kids and herself was put down as accidental drowning and an overdose was accidental poisoning. I have always been sceptical of figures. I remember being in the RTÉ studio and the individual who was interviewing me was at the other side of the counter. I just kept going and said, "No, let us get the truth out." It is very hard. The emergency department is obviously never good. We see it everywhere, even on movies and documentaries. The most chaotic place on the planet when you are in an emergency crisis is the emergency department. I do not think this Government listens, and certainly past governments in my own experience have never listened. I heard the talk about budgets, the 5% and the recommendation of the 10% in Sláintecare. In other places it is 12%. I do not like pointing fingers or making comparisons but sometimes the NHS can be miles ahead of us. Australia is millions of miles ahead of us, from teeny-boppers up with the Beats for the Blues initiative and the whole lot. We do still work in silos here and Departments protect their patch.

On the other side of things, when I was listening to the experiences from Professor Doyle's report, I wrote down little notes like the tick-box exercise in the accident and emergency. Mental health is still treated as a crime. You are actually guilty. That stigma has always been there. I remember that going back a long time now. If people are very lucky, they have their best friends. I have five best friends in my life and I am very lucky to have those. It is kind of hard. When my second brother died, my best friend never came to the funeral. I questioned him about it six months later and he said he just could not face me. He did not know what to say. Yet, I had put his very first son, who unfortunately had died in tragic circumstances, in when he could not put him into the coffin. That will tell you the close bond we had. However, that is the stigma that is attached to this. What all these people genuinely need is a hand on the shoulder. I have experience. Someone said to me a long time ago that I saved his life. I said I had not and that he had saved his own life by opening his mouth. He was walking down that road and that was the wrong road. We took him back, pointed him another way and encouraged him to walk the right way, but he did it himself. I always look at that. Everybody is very different but it is just to be calm, empathetic and have a listening ear. I do not care that it is 2026; it has not changed. The stigma with mental health is still there. The people who work in it are absolutely overstretched. They are not being supported. I have met many a psychiatric nurse who was crying. They are overstressed, they cannot do their job, they are out sick and yet they want to help.

I think Professor Doyle mentioned triaged teams as well. They are few and far between. Another one is families - families' feelings and armchairs and stuff. I am not going to go into how the coroner has treated Mr. Loughnane, but from my own experience my own feeling on this is that it is window dressing by the Government. It is throwing X, Y, and Z at it. It does not work. As Mr. Loughnane said, people need a safe, fully staffed service. I cannot understand how they can do pilot projects. We do not expect it to be rolled out overnight, but if something works in Galway and it will take six months to roll it out to, say, Cork, set the six-month target and start replicating it. However, all I have seen in the ten years I have been a Member of these Houses when it comes to mental health is excuses and a lot of tutting. It seems to be left to whoever is the best defender of young people in the country. There are those who trust in the youth clubs and those who trust, if they are sports-minded, in the GAA and rugby clubs. In fairness, the clubs have done a lot with mental health and gambling or whatever else. I read some of the statements of people in the opening submission that were not very supportive of An Garda Síochána. They are other people's statements, but from my experience a lot of people use gardaí as their first port of call. The GPs and the ambulance service were also mentioned. These are all amazing people but they are all totally stressed. When I think about the number of people in prisons who are suffering with their mental health, talk about going back into archaic times again. We seem to be going backwards. By even coming here today to keep this on the floor and keep it rolling again, I hope Government bodies and parties take it on board. I remember being very naive here in 2016 and 2017, having brought probably my first mental health Bill ever to the floor and the Chamber was chock-a-block. I was saying to myself they are all agreeing with it, but when it came to the final vote to do the right thing, it was defeated.

I will leave it at that. I do not want to question Mr. Loughnane. I just want to say “Keep doing what you’re doing”. I know there is a lot of anger and resentment because people do not teach us about our feelings, and especially when it comes to suicide, it is very hard to get an answer. The only thing I can say from my own experience is that instead of asking why it happened and why he did not see it coming, I think Mr. Loughnane has gone past that, and I congratulate both the witnesses for this. He is at the stage of asking what he can do to make sure no other family goes through exactly what they have, because it is not worth the suffering and the pain.

Gabhaim buíochas le Mr. Loughnane and Professor Doyle for being here. As the Chair outlined, we should not be having this conversation. We should not have to be addressing something that should already be addressed to support people in their time of crisis and need. I also thank Deputy Buckley for the way he spoke about it for the last few minutes and how he addressed his experiences and what he has seen in his time as an Oireachtas Member. He is right. There is broad cross-party support for improvement in mental health services. Adam's protocol and what Mr. Loughnane has put forward is so measured, well thought-out and considered, and the reality is it is based on real and unfortunate experiences. I do not want to go down the way of asking a load of questions. The report was said to have 15 questions for UHG. I do not want to go too deep into it but how has Mr. Loughnane’s engagement been with UHG over the last few months?

Not great, if I am being honest. We are meeting on Thursday for an open disclosure meeting about the external review. People understand external reviews and how they are done.

University Hospital Galway is a part of the Saolta hospital group. I had said from the outset that we did not want people from the Saolta hospital group involved and they said "Fine", so they got doctors from Mayo and Sligo, which are just the next two counties over. They said to me that if we had pushed for a properly external review, it would have taken a year for the report to be done. It did take a year for the report to be done, so that was a lie. I have gone through it in my opening statement. They took us in for hours and I outlined Adam's life and went through what it was like and how many times he had been in previously. My older brother spoke. We were honest. We told them everything about Adam's life and what happened to him as a child: domestic abuse, psychological abuse, issues with my father, stuff like that. We told them everything. I have the external review here. It reads great right up until the conclusion. It points out everything I have said: the hospital's rooms were not available, its liaison psychiatry team was not available, we said Adam required urgent attention but they ignored him and nobody checked up on him. Then their conclusion is that they have absolutely no idea why he walked out. To me, it is very obvious why Adam walked out. Again, I cannot speak about other people's loved ones but when I speak about my younger brother, and I would like people to bear this in mind, we are talking about a young man who got 600 points in his leaving certificate and a first-class honours in science in NUIG. This is a brilliant young man, highly intelligent. If you gave him advice, he would take it. If I told him to go to a counsellor, he would do it. He was just ignored on that day, and it is fairly obvious from everything we are saying. Physically, he looked fine, and this is what the nurses have said to me since. They have said that he looked okay but that - and this part, to me, makes no sense - when he was having this physical assessment with the triage nurse, who was physically assessing him and not asking anything about his mind, he was saying to that nurse continuously, over and over again, "I want to throw myself into the River Corrib. I have been thinking about it all day. I want to end my life in the River Corrib." They said, "You are urgent, category 2. You need to go back to the waiting room and wait for the liaison psychiatry team." That, to me, is a fundamental breakdown in the system right there. It is that point right there. His time is wasted and that nurse's time is wasted. He or she could have been checking on somebody who actually had a physical health problem. There was no need for that. From that moment onward, when he was led back to that waiting room, he was just ignored then. The only evidence they have is CCTV footage of him getting up at 4 o'clock. He looks over his shoulder and he walks out. As his older brother, I have been told that as he walked down, he had that bag in his hand. This was a bag he packed that morning because he had been an inpatient in that adult acute mental health unit on two separate occasions. The community mental health support worker said this to me. When they were driving there Adam said, "It will just be a few nights and I will be okay. I will just spend a few nights." That is why he had his pyjamas and a pair of socks in the bag. That is what he was like. He was a practical young fella. I even brought loads more stuff. He just brought two things. That is the type of fella he was. That is the last thing he had with him. That is the thing they found by the end of the river. He walked out with that because, as Professor Doyle said, he looked around and said, "I am a burden here. Nobody needs to see me here. I am better off just walking out."

So he showed up to try to save himself but the system did not show up to meet him halfway.

At all. Just on a practical level as well, and I have been saying this continuously, there are press releases in the Irish Independent and in other newspapers on that day, 11 February 2025, from University Hospital Galway, where it says its emergency department is overcrowded. These press releases are timed and dated: 10 o'clock, 11 o'clock, 1 o'clock. Adam called the hospital at that time and the clerical worker said, "Go to the emergency department." I am not blaming anybody there but there is complete lack of communication between the clerical staff who answer the calls from somebody who is suicidal and the emergency department itself, which had 100 patients in there, with both mental health assessment rooms in use. The consultant liaison psychiatry team was dealing with somebody else who was suicidal at that exact moment Adam was in there. To me, it is not even that they did not even meet him halfway; they just completely and utterly failed him.

I have nothing else really to ask at this point. I appreciate Mr. Loughnane's being here and the advocacy he is doing and what he is working towards. I read his opening statement where he highlighted the fact that €120 million could put an accident and emergency admissions unit for mental health in every county. That is real, it is tangible, it would save lives and it is a really well-put proposal. I have nothing else to add at the moment.

Unusually enough, there are very few questions because there is a fundamental agreement, I think. I do not want to put words in anyone's mouth but to judge from the way people are nodding, I think that is why. We do once again thank you, Mr. Loughnane, for being here.

I have Senator Andrews and Deputy Murphy, and if that is the last of the speakers from the committee, I will go to Deputy O'Hara then. I call Senator Andrews.

I thank Mr. Loughnane for his presentation. It is very powerful. It cannot be easy for him, and that comes across. I do not have any real questions as such. I agree with Pat about stigma. We hear that there is so much done and you can talk about mental health now and it is not like it was. I am not convinced that that is true. I think there is still a real stigma around it. If ending stigma is 10 on the scale, I think we are only at 2. That is my view. There is so much more we have to do. People come out with nice press releases and statements saying it is really positive and so on but the reality, from the little bit I know, is that it is not all positive and there is still a huge stigma ongoing. As regards the 15 questions Mr. Loughnane has for the UHG review, there are so many more Adams around. He has said that. I am in contact with a family now about issues. They could ask all these 15 questions and it would be the same. They have been let down by a system. So many young people are being let down day in, day out, and it is really frustrating. Teachta Pat Buckley talked about his health Bill. I see young families and the stress and the strain they are under and it is so difficult.

Cross-party support was mentioned. I know TDs and Senators on the Opposition benches. They have compassion. They are not devoid of compassion. Of course they are not. They know too. That is what I find really difficult to figure out. Everybody, as the Chair has said, understands and is in agreement on this, yet it does not translate to action or investment in pretty obvious measures that need to be taken. That cross-party support is not followed through in terms of investment in action, and I am not sure why that is. I do not know if it is related to that stigma. At election time, mental health and people's mental health are not an issue that is raised with me a lot, so then I wonder if the Government just says, "It is not a big issue among the electorate, so let us leave it." I do not know if that is fair or true. Possibly.

Mr. Loughnane is speaking for Adam and hundreds of other young people like Adam. I wish him the very best. Like Albert said, Mr. Loughnane has concrete, clear, concise proposals. It is not massive money, €120 million. That would transform communities and families and it would be great to see that.

I agree.

I apologise that I am not physically in the committee room. I am in my office for a particular reason. I thank Mr. Loughnane for his evidence, courage and advocacy on behalf of his dear brother, Adam, and for his powerful opening statement. It is something I have spoken about many times at a local level. It is something that I want to get more involved in at a national level, that is, why people have to present at accident and emergency units in the first place when there are no alternative pathways available. When somebody presents as suicidal, it is a mental health emergency; it is not a medical emergency. I often ask whether someone with a broken leg would present at a psychiatric ward. Medical accident and emergency units are designed for trauma, acute injury and physical illness but not a psychological illness. I have touted the idea that in every accident and emergency unit there should be some form of a crisis stabilisation unit where there is a calm, therapeutic surrounding. I thank Mr. Loughnane for putting forward some excellent examples worldwide. I note in particular the example he gave of Toronto in Canada.

I also thank Professor Doyle. The scale and scope of her research is really interesting in terms of what it says about why people present at accident and emergency. The service user experience in accident and emergency is predominantly negative. There are concerns around privacy and dignity. The focus is on physical care rather than it being a psychological crisis. It is interesting to see what the research says about what worked well, the impact on family members, the stigma around repeated presentations, and so on. What we are all asking for is dignity, privacy, compassion, skilled mental health assessment in a timely manner and clear follow-up with regard to safety and planning.

I am conscious that yesterday we announced a €1.2 billion capital plan. I am a newly elected TD. I want to make a difference. It is interesting that in this Thirty-fourth Dáil there are so many new TDs like me and Deputy Dolan, for example. Deputy O'Hara is a newly elected TD as well. There is an appetite in this Dáil for real and meaningful change. I will come back to the €1.2 billion capital plan for the HSE. Out of interest, I went through it county by county and counted the number of new emergency departments being planned. What are Mr. Loughnane's thoughts on incorporating into every one of those developments as an absolute must that there would be a crisis stabilisation unit to provide an immediate calm therapeutic surrounding?

I thank Deputy Murphy. When we are talking about the mental health accident and emergency departments and the EmPATH units, these are on existing hospital campuses. Very often they are reimagining existing buildings. They are not building new things. Most of the time they are right beside the existing emergency department. We are clear about that. It is quite obvious that if somebody comes through a mental health accident and emergency department, the person may need to be referred to the emergency department so these type of units need to be close together. There needs to be access to wider medical professionals other than just mental health professionals. Yes, I agree but again the crisis stabilisation unit is how they refer to them in Australia and parts of the UK, as a way of taking pressure off the existing emergency department.

I want to raise one point that ties in to initiatives. Deputy Buckley talked about this; that there are great initiatives but they do not really go anywhere. There is a suicide crisis assessment nurse service. I have not mentioned it yet but I just want to talk about it. There is a reason I want to talk about this. That has been around for almost 20 years – since 2007. I think I am right in saying that over the weekend there was an article in which Deputy Buckley's party colleague, Deputy Pa Daly, brought forward numerous stories about people losing loved ones to suicide and the Minister of State, Deputy Butler, who has responsibility for mental health, promised Kerry two suicide crisis assessment nurses. The programme has been in place for 19 years. How is it only hitting Kerry now? I come here with these proposals about mental health accident and emergency services but what will happen? They will open one up in Galway but in 40 years' time there will not be one in Wicklow. This is the problem here: that there is fantastic cross-party support and great ideas but they have to be delivered on. When we look at the HSE capital infrastructure that was delivered, all of that is amazing but we can already see that there is no accounting for the idea of mental health emergencies. They are now promising to build stand-alone mental health units that have been promised in areas going back decades but the reality of somebody walking out of an emergency department because of a mental health crisis is not being catered for in any of this capital infrastructure.

I come from a city where – Deputy Dolan and anybody else from Galway will be aware of this – just over the weekend somebody was found in the river. It was in the news. We have the permission of the person who told me, a family friend who contacted me last night. She said to me: "Joe, it is a tragedy that the week after you did an anniversary walk for your brother that this woman walked out of the A&E into the river and died by suicide." It has happened again. That is just a case where the family has spoken about it. I am not referring to other cases because I am not allowed to, as the families have not given me permission, but there are multiple cases of this happening every day in every county. Luckily, the majority of the time they walk out of the emergency department and they are saved. They are pulled from the river or they go to a loved one or they decide not to do it but there is a vast number of cases where it is happening on a weekly basis.

Somebody mentioned the coroner. I need to make this clear. Adam has been dead over a year and we have not had a coroner's inquest yet, so his death has not been registered as a suicide yet. There is another family campaigning on a similar thing. Noeleen Eustace's son, Kelvin, died over a year ago by suicide but there has not been a coroner's inquest yet. If you want to talk about the families, we are kept in this continuous limbo where we prepare for the review and the inquest. We are also being advised – I will say it publicly here - to sue the HSE. What is the point in that? The HSE is not going to establish a mental health accident and emergency service because we sue it. It will settle it outside court or something. We see those court cases in the news most weeks. The system is inherently broken if even a year after having died in Galway in the exact same hospital and the exact same river, the exact same thing is happening again. I will leave it at that.

Does Professor Doyle want to speak to the concerns raised by Deputy Murphy about the physical infrastructure and the make-up of accident and emergency units?

I agree with Mr. Loghnane. Co-location is the best scenario because there is almost always going to be a requirement for a medical assessment, medical triage, first but it is then a quick follow-up into a mental health specialist unit. Our data were extremely clear on what participants felt in emergency departments. I would like to make clear that we all know how absolutely run off their feet the staff are and what they are dealing with. It is not to cast aspersions on them at all but it is just to provide an environment where people who are at their worst, in complete mental distress, can be in a place that is safe, quiet and where they are kept in touch with the whole time. It is so important that they get that in whatever forum that looks like but certainly co-location would seem to be the best option.

We hear that. It was part of the presentation but also it is part of the evidence she is giving here this evening that we should not lose sight of the importance of co-location.

I thank the Chair for facilitating me. I thank the witnesses for their time today. I will begin by acknowledging all the work they have done in bringing this issue to the fore, and bringing public attention to the fact that so many people are being denied the support and care they need and deserve. For Mr. Loughnane to do that after losing his brother in such tragic circumstances is admirable. After his brother died, I am sure he was consumed by grief but his next thought was that this should not have happened and it should not happen to anybody else either, and that he was going to do everything he could to make sure it does not happen to anybody else in a similar position. He deserves huge credit for that.

Mr. Loughnane speaks very regularly on local radio in Galway about these issues. I know from speaking to people locally of the impact he has had through sharing his story, and the fact that he has pushed for change in this area has resonated with a lot of people who have gone through a similar experience. As he mentioned, unfortunately, we have had recent cases. It is shocking that these things do not evoke enormous public upset and anger, and that we have almost become desensitised to this issue. It is a regular occurrence in Galway city and, I am sure, in other places, and everybody is aware of that.

In Adam's case, he asked for help but the system failed him. That happens far too often. Both witnesses have spoken strongly and eloquently here, and have put forward very strong proposals as to how this issue can be tackled by providing real alternatives to people and proper crisis care in the community. As has been said, this is one of those issues where everybody is on the same page. Everybody can see the logic of what the two witnesses are proposing and why we need alternatives. Ultimately, it is about saving lives, and everybody agrees with that. However, we have not seen the action to match that or the improvements that are needed. My question to both witnesses is why they think that is.

The question is why I think there has not been any action by the Government to establish mental health A and Es. Again, I am not trying to cast aspersions on people. Sinn Féin brought a motion to the Dáil a couple of weeks ago calling for dedicated mental health assessment rooms. I thank Deputy O'Hara for speaking in the debate, and it is great to have Dáil representation among the members present. In that debate, the Minister of State with responsibility for mental health, Deputy Mary Butler, turned to Deputy O'Hara and said that she did not know about the work the NHS was doing on mental health A and Es. I am not a medical professional; I am an insurance underwriter. That is my job. This has all come from my brother’s death. Professor Doyle would have more experience than I. However, I knew about mental health A and Es, as many people do. The NHS published figures showing that across the UK, people were waiting nine to 12 hours at a time during a mental health crisis. It rolled out a plan. It said that this was its ten-year plan, and it was going to pilot it. There was an immediate response.

People who have gone to America and come back again are aware of the EmPATH units that have been set up over there. Dr. Scott Zeller, who was a member of a private health organisation, proposed this idea of open plan emergency departments with low lighting, soft music, rooms where people can sleep if they need to relax for a bit, sofas, beds, something to eat, a cup of tea and these types of things. Again, this is not stuff that you need to search through medical journals to find. It is all readily available information.

I do not think there is any political will. I am being honest about this. I do not think there is a lot of political will to change it. As Senator Andrews said, it is not an issue that comes up at voting time, and that is what I think is the reason. Not to be facetious but people who die by suicide are not going to vote. As for the families that are left behind, what was said to a lot of us in Galway when we went public with this story was that, eventually, grief will consume you, you will just hide back into that, and that will be it. That is almost what is expected of you: you have spoken out; now hide away again.

It annoys me, although I try not to get angry about this. Colette Douglas's son, Rob Douglas, died in Tallaght in 2021. The Dublin People interviewed her. She said that we need mental health A and Es because her son had died, and he was in and out. At the time, some local politicians said that, yes, that is 100% what is needed. In 2020, at Limerick City and County Council, Councillor Sharon Benson, again of Sinn Féin, proposed a motion. Limerick has a particularly bad situation. We all know what is going on at the hospital, which is destroyed. It is not just a mental health A and E that it needs but also multiple emergency departments across that area, because everybody is either going to UHG or UHL, and they are trapped between the two. It was proposed to the county council in 2020 that there should be a separate, dedicated emergency department for people in a mental health crisis, and that got unanimous support from the members of all parties and none on the Limerick council. That was five years ago but nothing has happened.

I think it is because there is no political will. There are no votes in it. Sadly, like a lot of the healthcare that we have in this country at the moment, it is privatised - it is about how much you have in your pocket to afford it. They know that with something like this, they would have to deliver it for free. I know that sounds harsh and cruel but that is the way I see it.

To be fair, we extended an invitation because we wanted to hear exactly what Mr. Loughnane has to say. Does Deputy O'Hara have further questions?

I ask Professor Doyle if she would like to come in on that. Senator Andrews spoke about the stigma around mental health, which was one of the issues raised by the respondents in the study that Professor Doyle carried out. What does she think we need to do to break down that stigma?

I think we are doing better with stigma. The fact is that people are presenting to the emergency department with their mental health difficulties. It is then a matter of what occurs in the ED. The stigma can become heightened when people see, as will happen, people with cardiac arrest or with sepsis going in first, while that person is left sitting there, often in a very open environment, feeling on show. The stigma begins to rise when they feel that they are being deprioritised. All of our participants understood the need for medical emergencies to be seen first but when they are sitting there with significant mental distress and the lowest self-esteem they have ever had in the world, that is not going to make them feel better. It is inevitably going to heighten stigma and decrease self-esteem. I think we are doing better with stigma. People are beginning to show up. It is what happens when they show up that is an issue.

To go back to the Deputy’s previous point, I cannot say why there is no priority behind this. I want to outline that there is complexity here. It is not necessarily a black-and-white issue to build or make an alternative mental health A and E as a separate department. We have to understand that suicidal behaviour is one level of presentation to the ED but we also have people with psychosis who are hallucinating and people with severe anxiety. All of those will require medical assessment. There is more complexity here. Certainly, the research nationally and internationally, in fairness, shows that the environment of the ED is really not the place to be. We have seen this in the experience of our participants, and we have seen it in the case raised by Mr. Loughnane, that people sometimes just get up and leave. That is the last thing we want. We want to keep people. When they have taken their courage, and it takes courage to present yourself to an ED, we want to keep them there. That is the environment that we need to find.

I have some questions and observations. I do not know if this is exactly declaring an interest but before I was elected, I was a trade union official. I represented psychiatric nurses at the time the SCAN nursing model was being introduced. I am not going to speak for the nurses but I will give my recollection. I believe there was a genuine belief among the nursing community that this would be very beneficial. I think we need to understand this from the perspective of the people who are working in accident and emergency, whether it is a nurse, a porter, a doctor or whoever.

They come in every morning and are doing their best. However, there are people in accident and emergency departments who should not be in them but who have no option. It was just pointed out to me that if you look up the Jigsaw website in a crisis, it will direct you to the accident and emergency department . On the one hand, I believe the last place the individual should be is an accident and emergency department but sometimes the alternative is not an option. There needs to be another door or separate corridor, but the accident and emergency department is a door.

I know from having represented nurses who work in accident and emergency services that they want to look after everyone who comes through the door, but there are people who are not trained or do not have the time to help. It is not their job but they do their best. They will tell you themselves that all they can provide is a sticking plaster because they do not have the time, training and space. The space is important. I understand what Mr. Loughnane said about buildings already existing but the space is important.

A couple of weeks ago in Balbriggan, a family came to my office whose son of 16, or nearly 17, was experiencing suicidal ideation. They had taken him to the accident and emergency department and, in their words, they had nine of the scariest, most awful hours of their lives. They left and brought their son with them. They did not have a good experience in the accident and emergency department. It is the same as has been said here. They did not in any way blame the staff in the accident and emergency department because they know that while they were in the wrong place, they were also in the only place. There was nowhere else. When they had to call the Garda, the accident and emergency department was where they were advised to go. If you google "mental health emergency", you will be advised to go to an accident and emergency department. It is important that the committee say to people that if the accident and emergency department is the only place to go, they should go there. However, in the meantime, work needs to be done to create a separate space for people.

The points made by Professor Doyle on the space pointed to the complete lack of any dignity or privacy at the worst time in a person's life. The person is nearly in the worst place, yet he or she is in the only place. It cannot be the worst place because it is the only place. That conflict exists. There is no disagreement here at the committee and we certainly will correspond with the Minister for Health to try to get some answers to the questions. As politicians with our respective roles in our political parties, we must try not to let this issue drift past. I feel it has.

The scan nurses, when I represented them, were rightly celebrated. The idea was deemed great and a fantastic intervention, but if scan nurses are not in every single accident and emergency department, which they are not, and if there are senior people in government or the health service who do not know about the service and the difference scan nurses would make, we all have a bit of talking to do to try to highlight the issue.

We will correspond with the Minister for Health try to get the answers to the questions. I was going to say they are fairly straightforward but they are not. However, I am fairly sure the questions are straightforward enough for the Department, with its hundreds or thousands of staff, to be able to find someone to answer them.

I am going to close on my next point because I do not have a question. Most of us did not have a question this evening. Sometimes we question people when we do not agree or understand. While we may not know the pain the witnesses are experiencing, we understand grief and what motivates them. There is no disagreement here. There is agreement that we should write to the Department. We will try to get some answers for the witnesses and send them the responses as soon as we get them.

I should have said that our two Senators had to leave because a vote was called in the Seanad. That was no reflection on the meeting.

I thank our guests again, not just for being here this evening but also for all of the work they do. Their words are very much heard, understood and respected. They are a call to action and we are listening. I cannot thank our guests enough. I genuinely do not know how they find the strength to appear here but we are grateful that they have done so and for their voice.

Since members have no more questions, I am going to suspend the meeting for a few minutes just to allow our witnesses to take their leave. I thank them again.