I welcome the Minister of State, Deputy Butler, and her team from the Department.

Amendment No. 161 is a Government amendment. Amendment Nos. 161 and 162 were already discussed with amendment No. 2.

Amendments Nos. 163, 164, 167, 170, 175, 180, 184, 190, 192, 197 and 294 are related and may be discussed together by agreement. Is that agreed? Agreed.

The amendments in this grouping change the words ", or refuse to consent to," with "or refuse". This is being done to ensure consistency in language across the Bill.

Amendments Nos. 165, 166, 168 and 169 are related and may be discussed together by agreement. Is that agreed? Agreed.

Amendments Nos. 165 and 166 are minor wording changes, adding "responsible" in front of "consultant psychiatrist" in the former and replacing the word "another" consultant with "second" consultant These amendments are to ensure consistency in language across the Bill.

Amendment No. 168 moves the existing section 64(4)(b) to new section 61(5). This is not a new policy, but instead places the provision in a more appropriate section. It provides that where a capacity assessment is being carried out on a child, it is done as soon as practicable, regularly to meet the individual child's needs, but not less than once every 14 days.

Amendment No. 169 inserts reference to the "capacity assessment under subsection (1)" along with subsection (2) already referenced, to correct an omission in the published Bill.

I will be brief because, in fairness, taking an overall assessment of all our work to date, we have covered off on a lot of stuff, and once we move away from this section, the sections up to section 91 all deal with children. I have some thoughts and I want to share them with the Minister of State rather than adding additional amendments to today's proceedings.

It is vital that the children in involuntary care or subject to restrictive practice have access to an independent complaints mechanism. I have said that. The Minister of State knows where I stand on that and she knows her position on that as well.

I have spoken to a number of people who have observed the proceedings here and there remains a concern in relation to the administration of restrictive practices against children. This is all sort of covered off in the Bill.

I am only going to share this concern; I am not asking the Minister of State to get into a long, protracted debate. I merely want to bring to Deputy Butler, as Minister of State, the concerns of the public and people involved who are working in this area. This Bill will continue to allow for mechanical restraint, physical restraint and seclusion of a child and states that the restraint used must be determined "after the age, size and physical vulnerability of the child has been assessed and considered by the person ordering the restrictive practice".

Having looked at the Bill again today, I note it requires that the registered proprietor of an acute mental health centre must notify the commission in each application of restrictive practice in respect of a child in that registered acute mental health centre or mental health facility and I suppose the real question is whether the commission will review all such cases. As the Minister of State said, there are not many, but there are a sizeable number.

I also have had a look at some of the parliamentary questions. I note it is a different practice, but I am not going to comment about the Dáil. I am not a Member of Dáil Éireann. Many of the parliamentary questions now are referred directly to the HSE for a response. I have a copy of the HSE responses but I am not going to go into all of that here.

If the commission would review all such cases, such reviews would help monitor patterns, ensure compliance and identify systemic issues. We have seen already, without going back into it, the case of Bloomfield where the Mental Health Commission had statutory responsibility and gave a 94% approval rate for three consecutive years. The Minister of State and I know, and the public knows, and the Dáil knows and this House knows what happened there without me going into all again. Would the Minister of State consider introducing some sort of statutory requirement for post-incident reviews involving the children and their families and their independent advocates to assess the necessity and the impact of such an intervention?

How will the Minister of State ensure that the rights of the child, including the rights of those involved, will be heard and respected? That is the question. Would the Minister of State consider it? I am not saying the Minister of State needs to give me her response instantly; she will be back, of course, with this Bill.

Are there any further reassurances the Minister of State can given in terms of the role for the commission to review such practices? If that is possible - the Minister of State may need to consider that with her officials and her medical mental health experts who would advise her from time to time and with her own knowledge of the event - there is a strong case there. With the best will in the world and the best intentions of people who are directly working in mental health care and people who have lived experience of these services, we must put it in place because we are now developing primary legislation on mental health care that hopefully will serve the country and the mental health sector for the next ten to 20 years. There may be a case but I would be interested in hearing the Minister of State's response.

If I could, I welcome Deputy Aird and his guests to the Gallery. I hope they enjoy their visit here to Leinster House. I call the Minister of State.

I will speak briefly to this because I have spoken at length about restrictive practices. I have also spoken about the huge advances we have made in the reduction of restrictive practices. The Senator refers specifically to children in this case.

Any use of restrictive practice must be proportionate, in rare and exceptional circumstances, for the shortest duration possible and where there is no safe alternative.

Any child who is involuntarily detained in an approved centre would be very ill. That is the first thing I would say. They would have a very serious mental health disorder, challenge or illness. In most instances, 22 of the 52 beds that are open are being used for children with an eating disorder. They are very sick. Eating disorders are the most serious mental disorder one can have in relation to loss of life. In some cases, unfortunately, people with anorexia nervosa might have to be supported to ingest food. The commission is always informed of any seclusion or restraint that is necessary. The commission monitors all uses of restrictive practices. It publishes a report on restrictive practices every single year. The report tracks the usage and trends. We have seen the most amazing reduction over the last three to four years. When I attended the World Health Organization conference last year, it was noted across the whole of Europe. This has only been done with the co-operation of all the staff who deliver these services, whether public, private or voluntary. Nobody takes a decision lightly to restrain or seclude a minor. I am very confident of that. Unfortunately, what sometimes might be forgotten is that in the case of a very ill child or young teenager with an eating disorder, there are situations where tube feeding is necessary. That has to happen where there is a risk to the child's life. In 2023 and 2024 there was a 34% reduction in the number of reported episodes of seclusion and physical restraint. Since 2018 there has been a 62% reduction in all restrictive practices. That is significant. No other country in Europe can say that. Senator Boyhan is talking about a very small minority of cases. I get that. I am confident that we are monitoring this extremely well.

Much of the Bill relates to the governance of CAMHS but inpatient CAMHS is governed by the Mental Health Commission. All services are subject to unannounced inspections at any time of the day or night. In fairness to the Mental Health Commission, it takes restrictive practices, be it seclusion or restraint, very seriously. I am confident that through my constant engagement with the Mental Health Commission, we do not have to take it any further than that at the moment.

I thank the Minister of State. I hear what she says. She has set out her stall on the record of the House and she is confident. Inspections are difficult. We will talk about that later in terms of access by the Mental Health Commission to facilities and resources. In some cases we are talking about once every three years. I accept it still has the right to go in. I am familiar with that too. I will leave it at that. I hear what the Minister of State says. I ask her to keep an open book on it. The measure should be reviewed from time to time. Even the fact that we are having this debate is improving standards. It is shining a light on this issue. I have spoken to three journalists this week who contacted me about the Bill. That is all to be welcomed because we are now shining a light on issues that were not always vented.

There were not that many people involved in the mental health debate. Even within the Chambers in both Houses I see there is not a huge amount of engagement on it. That is not to pass judgment, as Members have other areas of expertise and, as we speak, they are at committee meetings. There is a need to be vigilant about post-incident reviews. They are needed from time to time. With the best will in the world, they are required. The Minister of State has outlined her position and I accept it.

I welcome any opportunity we get to discuss mental health in these Houses. Last night, for example, Sinn Féin had a motion on crisis intervention and supports, which I accepted. We had a very good debate. Any opportunity we get to discuss mental health in both Houses is very important. I will always show up, as the Senator knows, for any debate relating to mental health. I am never found wanting in that way. It is important that we get the opportunity. I thank everyone who is present, the same people who have consistently been here the whole way through. Senators and TDs have different roles on which they lead and they are also at committee meetings. People often look in and ask where everybody is, but I guarantee that everyone is busy doing something else. There is always a spokesperson for mental health in each political party or group of Independents. I note Senator Boyhan's observations.

I thank the Minister of State.

Amendments Nos. 174, 177, 182, 183, 185 and 187 are related and may be discussed together by agreement. Is that agreed? Agreed.

Can I speak to my amendment?

Yes.

I have tabled amendment No. 187. I totally understand that this has already been discussed quite a bit so I do not want to spend a huge amount of time on it. I know this is something the Minister of State feels extremely strongly about. That said, while I can see where she is coming from and I acknowledge the personal story she told recently, I also want to put this on the record. I hope she can see where I am coming from and my concerns at this point. As I have said before, I fully acknowledge and applaud the Trojan work the Minister of State and the Department have done to significantly decrease the number of children admitted to adult units in recent years. I know it is not an easy thing to do. It is something that I am sure has made a real difference to many young people. As I said before, I have concerns about the fact that these figures could possibly rise again if someone else who comes into the Minister of State's role does not have the same compassion and understanding that she has and might possibly not monitor the figures as closely as she does. I know she said no clinician wants a child to be placed in an adult unit. I am sure she is right about that, but the reality is that the numbers were high when the Minister of State first came into the role. I am concerned that they may become significantly higher again in future if there is no real legislation protecting against this practice.

The Minister of State noted her concerns about a 72-hour window, in the sense that it could make the practice more commonplace. Again, I totally understand where she is coming from. Ideally, this practice should be completely prohibited. That said, my amendment is trying to allow for the very rare and exceptional emergency situations the Minister of State referenced when placing a child in an adult unit is the only immediate option, for example where there is an urgent risk to the child's life or safety and no child-appropriate bed is available. In such cases, it is essential that the law, at a minimum, include strict limits and clear procedures to ensure that these placements are truly a last resort. In these cases I believe there is no justification for a child to ever remain in an adult unit for more than 72 hours, which is three full days. During that time there must be a clear and active obligation on the relevant services to find a suitable age-appropriate placement. It would be so powerful if we could put something like this in the legislation to protect future generations of children. I will leave it on that point because I recognise that, in fairness, the Minister of State has spoken a lot about this. I just wanted to put how I feel on the record.

I will be brief as well because we have spent a lot of time discussing this issue. The reason I feel so strongly about this – it is not all down to me, because everything is a team effort – is that there are now practices in place whereby consultants, psychiatrists and multidisciplinary teams look at the situation and make a decision on that basis.

I do not see any reason for the numbers to increase, however. The reason is that there are more community supports than ever before; 95% of all those with an eating disorder are being treated in the community. My main worry, if we were to legislate for 72 hours, is that it means we are legislating for children to be admitted to an adult ward because that is the way it would have to be worded. I have discussed this with the Office of the Parliamentary Counsel. If we are going to say they will not be kept any longer than 72 hours, that is actually opening the door to say we are legislating to put children into an adult ward. That is the last thing I want to do. I want the practice to get to zero. There may always be individual cases. I have spoken of them, and I knew about a real case. There may always be a handful of those cases every year. To reiterate, in the case of a 17-year-old, it is always with the support of their families, and it is always an individual room with clinical supports for the duration of time.

I understand the point the Senator is making about when the initial transfer is being made, but where we have improved now is that we have capacity in the units across the country. Dr. Amir Niazi appeared before the Joint Committee on Health last week and spoke about eating disorders. He spoke about how there was 30% available capacity last year on average across our inpatient CAMHS units. Coupled with that, I secured the funding to reopen the beds that were closed in Cherry Orchard this year. I also secured the funding to start opening the new children's hospital beds with ten beds. That is an extra 21 beds. I really believe that unless if we had some kind of weather disaster that meant that somebody was not able to travel, I do not really see any reason. We have capacity now that we did not have previously, both in community and inpatient services. That is the reason. I understand where the Senator is coming from because she does not want to see anyone there for any length of time and neither do I. I do not want to see anyone there at all, the same as the Senator. If we legislate for it, however, we are actually opening that door to say that clinicians can put children into an adult ward, even if it is only for up to 72 hours. We are actually opening the door; I just want to keep it closed. I understand and appreciate the way the Senator has presented this.

I move amendment No. 187:

In page 75, between lines 20 and 21, to insert the following:

“(4) Where a child is admitted to an adult acute mental health centre pursuant to an involuntary admission order made under section 66, the Executive shall ensure, in so far as is practicable, that this period shall be no longer than 72 hours before the child is transferred to an age-appropriate centre.”.

Amendments Nos. 188, 189, 191, 194 to 196, inclusive, 199, 201 to 203, inclusive, 205, 207, 210 to 212, inclusive, 217, 221, 234, 235, 238, 241 to 244, inclusive, 251, 253, 258, 260, 261 and 263 are related and will be discussed together by agreement.

These amendments as a whole relate to the sections concerning the involuntary admission of children and related matters, such as the application to the District Court to involuntarily admit a child, the application to the District Court to renew an application or seek the discharge of a child, the right to appeal a decision to the Circuit Court and the introduction of safeguards for children and young people, such as the right to receive information.

The amendments in this grouping are generally smaller in nature. Many of the amendments relate to inserting references to subsections that need to be updated or relate to changing terminology. We spoke about this previously, for example, changing references from the District Court to the Family District Court, which are the changes made in the Department of justice. Other amendments clarify how the involuntary admission process works, such as the requirement that consultant psychiatrists would deliver reports on examinations of children to the court within 72 hours. I will speak to some of the more substantive amendments in this grouping.

An important one, for example, is amendment No. 207, which inserts new subsections to ensure that any guardian ad litem appointed to the child is notified of a proposed application to the court in advance, which is really important, and copies of the proceedings are served on Tusla and any other person the court decides.

Amendment No. 234 replaces section 70 with new text to provide greater clarity on the process for discharging children who have been involuntarily admitted. The amended section 70 was drafted following consultation with the Department of children and better reflects the role of parents and Tusla, where involved, in the discharge of a child.

Amendment No. 238 sets out the process and timelines for sittings for the hearing of applications for involuntary detention for children at the Family District Court and the course to be taken where there is no judge or sitting available in the timelines set out, in that an application may be made to the next sitting of the District Court, or made ex parte if the judge is satisfied with its urgency. This will ensure that a court will always be available to hear applications for involuntary admissions. The default jurisdiction will be the Family District Court, but the regular District Court can hear such applications if it is not possible to schedule a family court sitting.

Amendment No. 243 inserts a new section, which provides for the bringing of a child to a mental health centre where an involuntary admission order has been made. In the first instance, the child should be brought by his or her parents or guardian. However, if the parents or guardian are unable to bring the child, the section provides a legal basis for the parents or guardian to request the assistance of the clinical director of the centre to provide assistance.

I wish to reassure everybody here today and everybody watching that all of these amendments were recommended by the Department of children to ensure it will be as untraumatic as possible for any child who has to go to court or be involuntarily detained and to improve the experience of the children. For example, the parents or guardian would bring the child if he or she had to be involuntarily detained and different things like that. We had a lot of consultation with the Department of children to improve this part of the Bill. That is the reason I am bringing forward these amendments at this stage.

I welcome the four guests of Deputy Buttimer. I presume they are from Cork. I hope they enjoy their visit to Leinster House today.

I want to ask about amendment No. 217, which concerns District Court renewal orders and the requirement that a child be examined by a consultant psychiatrist within 48 hours prior to the renewal. In the original text, a consultant psychiatrist was expressly disqualified from conducting this examination if he or she had been involved in the child's care or treatment, ensuring that the assessment was carried out by an independent clinician.

Why is that provision being removed? The consultant psychiatrist in question should be independent, as an additional safeguard for the rights of the child. I would like a bit more information on amendment No. 217.

We are dealing with a large block of amendments. I draw the Minister of State's attention to amendment No. 234 to section 70. We are dealing predominantly with children here and this is specifically to do with the discharge of involuntarily admitted children. This is a ministerial amendment and what drew my attention to it was-----

Sorry, is the Senator referring to amendment No. 234?

Yes, I am talking about amendment No. 234, which is on page 29 in the list of amendments. It relates to the section dealing with the discharge of involuntarily admitted children. We are talking about the role of a parent, guardian or representative of a child, there being various degrees of involvement depending on sets of circumstances. I note the Minister of State's comment that in drawing up many of these amendments, she engaged extensively with the Department of children. The amendment refers to "[providing] the child with all relevant information from the child's care plan prepared in accordance with section 180" and information regarding same. I would like some clarity on that.

On page 30, the amendment refers to "where the child is the subject of a care order, a voluntary care arrangement, an emergency care order, an interim care order or a supervision order". We have talked about these different orders. It is quite complex and there are a number of options. The amendment goes on to talk about the importance of a care plan. That is all perfect if everyone is on the same page regarding the care plan and if the child's parent or guardian is fully aware of the care plan and is briefed fully in relation to it.

This is a very long amendment. On page 31, it states: "Where a child the subject of a care order, a voluntary care arrangement, an emergency care order or an interim care order is discharged under this section, he or she shall be released into the care of the Agency." This is an issue I would like to get a better handle on because we hear of so many cases where there is not quite that ease of transition in respect of a care order. As we said earlier, it is about empowering the individual concerned in relation to these matters. When considering a child in State care or another form of detention, and bearing in mind there are many forms of care and many places other than the home place, the Minister of State has reassured us by saying she has talked to the Department of children and that it is on board, which is interesting.

I do not know whether she had any engagement with the Ombudsman for Children on this particular amendment but I know he is highly sensitive to issues to do with all children, which is his remit, up to the age of 18. There must be an emphasis on the importance of the multidisciplinary integration of care orders and ensuring that the children and their parents or guardians are fully versed in that and there is that engagement. I would like greater clarification - if not today, then by way of a simple memorandum - on how all of that relates to the various State agencies. We have Tusla, residential institutions, children committed for various reasons through the courts, children in either short-term or long-term foster care, adoption, placement orders and so on. It is very complex and particularly so when children have had many moves as part of their care. We know it is an area where children have fallen through the cracks historically. I do not particularly want to mention individual names or cases here, because that is not appropriate, but those cases are known to us. Some of those children died under terrible circumstances. When we look back at the evidence, including the coroner's reports, we see issues in terms of mental health and who was responsible for and taking care of the child.

I do not want to place blame on anyone in respect of historical cases. What I want to know is whether there is any way, through this legislation, to strengthen that element. I am saying there must be stronger continuity in the engagement in the various processes in order that no child falls through the lines and that all stakeholders involved are aware of, and fully versed in, the care plan. That is the point I am making.

May I confirm that we are discussing amendments Nos. 173, 174 and 177? Is that right?

I am talking about amendment No. 234, which is in the group we are currently discussing.

We are discussing the group containing amendments Nos. 188, 189, 191, etc. and including amendments No. 234, 235 and so on.

Yes, amendment No. 234 is on that list.

These amendments relate to section 66 and subsequent sections.

Amendment No. 234 is in that group but way down the list.

The Senators have moved on more quickly than I have.

That would never be the case. Amendment No. 234 is in that group. I am sorry for the confusion.

That is fine, Senator. It is just there are so many amendments and we have spent a lot of hours on the Bill.

Amendment No. 217 proposes:

In page 77, lines 34 to 36, to delete all words from and including "she—" in line 34 down to and including line 36 and substitute "she is a relative of the child concerned.".

Is that the amendment to which Senator Black referred?

Yes.

The court will provide the necessary independent oversight. A Bill of this nature involves interacting with other Departments, as we have spoken about in respect of the Department of justice and the changes it made in regard to family courts. In addition, as I said, a lot of these amendments came from the Department of children. My understanding is that the court will provide the independent oversight that is necessary.

Amendment No. 234, which is a lengthy amendment, was also drawn up following consultation. These orders were put in place at the request of the Department of children. The children concerned will be in the physical care of Tusla the whole time, which is really important to understand. The section is to ensure there are appropriate discharge pathways for every child, regardless of his or her status. We spoke about that last week in relation to the types of care. It does not matter how the child presents, whether via public, private or voluntary care or through Tusla. That child will be cared for appropriately to deal with the mental health issues he or she presents.

These amendments are also to ensure the same level of legal safeguards under this Bill will be in place for children in court proceedings as apply to children in court proceedings under the Child Care Act 1991. A huge amount of time had to be spent aligning this part of the Bill with various other Acts that are really important.

The amendments also ensure that in cases where Tusla is the legal parent of a child, an issue Senator Boyhan has raised throughout the debate and about which I know he is deeply concerned, that child can be admitted to inpatient mental health services, and that, while in the care of Tusla, consent to the admission, treatment and discharge of that child is treated in exactly the same way as for any other child. Tusla is acting as the parent or guardian of that child at that time.

I thank the Minister of State for clarifying some of the points I raised. My concern is really about the importance of the care plan that is to be prepared, which she has acknowledged and is in her amendment. Ensuring all the stakeholders involved in children's care are engaged with the plan is important. That might be their social worker or advocate because, in many cases, the parent or guardian does not enjoy a good, healthy relationship with the child, or vice versa, because there is so much historical trauma or even, in some cases, abuse. I am not here to demonise Tusla but we all know what happened to some children in its care. As I said, I am fully aware of those cases but it is not appropriate for me to name the children involved.

There are processes, coroners' courts, investigations, tribunals and ongoing inquiries. They all have to run their course and all do. We have had too many cases where people either lost their way or lost their lives through mental illness. Some, but not all, were in the care of Tusla. They are the most vulnerable of vulnerable people. The really scary aspect is the number of children, particularly teenagers, about whom no one seems to care, or who themselves feel no one seems to care about them. There is not a night when walking home on the streets around Leinster House that you do not meet young people who are so vulnerable and who may have become involved in drugs or prostitution. They are seeking affirmation, support or someone who expresses remotely any interest in them. They are broken, and they are broken through a system. No one here is denying it but we have got to reach out to them and to the agencies. If anyone has time to go to the District Court, he or she will sometimes note cases where there is no one present to represent the most vulnerable. There are many great Government-funded charities engaged in outreach and there are many good pastoral ministries, but these are very low-key operations.

Everyone, most importantly the child, must know there is a plan. The person must have as much input into it as possible, given his or her circumstances, although this is not always possible. The provision in this regard is one of the most critical in the Bill.

I say to people all the time – sometimes it has to be made very simple – that Johnny or Mary on the street outside today, or anyone who is vulnerable, is someone’s son, daughter, brother or sister. That is how you have got to bring it home. We are here not to complicate things but to highlight that people’s care plans are critical. More important, a care plan must be seen through. Those affected are children.

I am happy with the Minister of State’s explanation. There is no distinction in terms of the pathway, as she has made clear. The pathway is open for everyone. However, we know that when you are vulnerable and no one has that much interest in you, you do not necessarily have an advocate or guardian pushing things along and supporting you in your care plan. That is just part of the system.

We have a good understanding of what we are about on this particular section. Did the Ombudsman for Children have any commentary about this? Maybe he did not. I do not know. Maybe the Minister of State will share it.

I want clarity on amendment No. 243, just for my own understanding. Amendment No. 243 covers the bringing of a child subject to an involuntary admission order to an acute mental health centre by gardaí. Will any safeguards, training or guidance be made available to ensure Garda involvement is used only as a last resort? It should be trauma-informed to minimise distress. The reason I say this is that a few years ago, when I was on the mental health committee, I had a meeting with a young man who was having a really bad episode. He was in a bad way in the sense that he was lashing out. The gardaí were not really informed as to what was going on. They just thought he was having a mental health episode. He was treated absolutely horrifically on one occasion. On another, he was treated with wonderful empathy and understanding by the gardaí. I need clarification on this as well. On the occasion that the individual was treated badly, the garda was not trained to deal with somebody having a mental health episode and was therefore very aggressive. The young man was retraumatised. He was involved with an organisation whose name I cannot remember. It was a really bad scenario for him and he went into a very dark place. Is there any oversight or review that could be conducted in such cases to ensure everything was done properly and to ensure continuous learning from the Garda’s point of view? That is really important.

Amendment No. 238 does not explicitly reference the child’s right to be heard or to have legal representation during proceedings. Can the Minister of State provide more information on how these rights are protected? Can assurance be given that these points are covered elsewhere in the Bill? While the amendment states the executive must furnish psychiatric reports, there is no real mention of an independent review, access by the child or his or her representatives or an opportunity to challenge the findings of the reports. All of these are essential for procedural fairness. Could we be given some clarity on that?

Senator Boyhan raised the issue of equality. Equality is a principle enshrined in the Constitution, as we know, and we must ensure no child is disadvantaged in accessing any service because he or she is not under the legal guardianship of his or her parents. The principle is one that we all hold very dear.

I am glad the Senator raised care plans because we have not spoken much about them at all. As Minister of State for older people and mental health in the previous Dáil and as Minister of State for mental health in this Dáil, I feel very strongly about care plans. Over recent years, I have spent a significant amount of time reading HIQA reports on nursing homes – public, private and voluntary – and Mental Health Commission reports. It is often found that a care plan might not have been implemented or that there was not enough care planning.

The Bill states that a care plan will be made with the child. The child’s parents will be involved if the child comes from a family background or family setting. If the child is in the care of Tusla or guardians, Tusla will be involved in the child’s care planning. Involvement in a care plan, whether for a child or an adult, ensures the person’s voice is heard. I speak all day long in my brief about will and preference. These must be part of what we want to achieve. This Bill will strengthen provisions in this area.

What amendment did Senator Black refer to?

Amendment No. 234.

In relation to the Garda?

Yes.

It is quite a while since we discussed this part of the Bill. When this Bill is passed and enacted, gardaí will no longer be involved in involuntary detentions. They will be completely off the pitch. This is what the Garda wants and what we want to achieve. We will have authorised officers instead. At present, there are approximately 117 authorised officers trained. The majority of them work in mental health. They might be social workers or mental health nurses. Before we can enact the relevant part of the Bill, we would have to have around 400 or 500. We may also need full-time authorised officers in big city regions, though not so much in rural areas. Therefore, there is a substantial amount of work involved.

As soon as my team gets the Bill through the Dáil and Seanad, with the support of Members, it will consider how to enact the Bill and secondary legislation. It will be phased in, in many ways. We will have to ensure, and I will have to be confident, that we have enough authorised officers. We know we have gardaí all over the country. Thirty-three percent of all involuntary detentions last year were proposed by the Garda, for example. We have to be in a position to deal with this.

I was sorry to hear about the situation the Senator spoke about. Seeing a garda now might have a triggering effect on the individual concerned. What happened has taken over a huge part of his life. Having authorised officers qualified in the area of mental health is important, notwithstanding the good work done by gardaí in the difficult situations in which they find themselves.

We need to see more of what we are doing in Limerick in relation to community access support teams, CAST, a pilot project on which I have worked closely with the Garda, HSE and regional executive officer Sandra Broderick. Where an issue arises with mental health – this is more for adults – and gardaí deem it safe, a clinical nurse specialist, or other clinician, in mental health attends.

The results are absolutely a game changer. They are phenomenal. We often roll out pilot programmes and we look at them and think about what we need to do. The Minister, Deputy O'Callaghan, is very taken with it as well and we want to mainstream it. It will take time, there is no doubt about it. However, at times when a lot of people come to the attention of the justice system and the Garda, it is care they need as opposed to a prison cell. This is what we want to see achieved.

As Chief Whip, I am in charge of all legislation going through the Houses at the moment and I had a legislation meeting today. We looked at when we pass this phase in the House and then pass the enactment phase, the fact is that we will come to a stage - believe it, or not - when the Mental Health Act 2001 will cease at midnight one night and the Mental Health Bill 2024 will come into law. Those who are involuntarily detained on the following day will all have to be reassessed because the terms of the 2024 Bill are more human rights focused. The person who is involuntarily detained and those who are there voluntarily will have more rights. That is where we are trying to focus our minds at the moment because that is a huge body of work as well. It is like the time we moved all the residents from the Central Mental Hospital in Dundrum, which was under my watch at the time, all the way out to the forensic hospital in Portrane.

The whole purpose of these amendments and all the ones we have discussed here are as a result of consulting with and requests from the Department of children. I met with the ombudsman before Christmas. We had a long chat and he discussed the main concerns he had. He is very strong on minors being treated in adult facilities. We had quite a good meeting and he raised any real concerns he had but I cannot for say for definite whether he was involved in that particular amendment. We can check it out.

Is the Minister of State generally happy with the amendment? I do not want to get into specifics, but did the Minister of State took on the ombudsman's concerns? He has issues with children being treated in adult facilities but is the Minister of State happy that he got a good hearing?

Yes, he did.

I do not doubt that. Is the Minister of State happy that she has endeavoured to incorporate the ombudsman's concerns into this Bill?

Yes, I do. On that particular day, I had officials with me and he had officials with him as well. We had a good meeting for about 90 minutes and we went through several elements of the Bill that he had concerns with. I told him my direction of travel. Some changes have been made to my direction of travel since I met the ombudsman but, while I do not think anyone can be 100% happy with any one Bill, what I am trying to do through my work with the Department of children is ensure that there will be no unintended consequences and that the experience for the child will be the best it possibly can.

I welcome Deputy Dolan and his guests from Galway East this evening. I hope they enjoy their visit to Leinster House.

It is wonderful that there are authorised officers now. It is really powerful but unfortunately it allows for gardaí to still bring people to centres. I imagine that it can be very traumatic. If I have an adult child who is having an episode and I ring the Garda and a garda comes, he may not understand what is going on and could react in a retraumatising way. There has to be some form of safety for that individual. I question whether this issue should be reviewed and I think there should be some kind of training for gardaí. It is important for the individual having an episode and for the family as well. It is important that this is considered. I am worried that this amendment still allows for gardaí to come and take that person away.

No, I did not answer that comprehensively and I will now. There will be regulations made to ensure that Garda powers are used appropriately. Gardaí can and do currently attend to mental health presentations for children but the use of Garda powers will be used as sparingly as possible. We will address all of that in the next stages. The enactment piece is hugely important. That will be phase 2 and I will be back to the House again.

Amendments Nos. 228, 229, 231 and 233 are related and may be discussed together by agreement. Is that agreed? Agreed.

I move amendment No 246a:

In page 84, line 29, after “admission,” to insert the following:

“including adequate information in a form and language that the person can understand on the nature, purpose, likely effects and potential side-effects of the treatment concerned,”.

I move amendment No 247a:

In page 84, line 37, after “Chapter 3,” to insert the following:

“consent in this case means consent of the person obtained freely without threats or inducements where adequate information in a form and language that the person can understand on the nature, purpose and likely effects and potential side-effects of the treatment concerned has been given to the person,”.

Amendments Nos. 264 to 268, inclusive, 271 and 273 are related and may be discussed together by agreement. Is that agreed? Agreed.

I seek clarity on the new sections 77 and 78. We are talking about members of staff of a registered acute mental health centre or a service provider. I ask the Minister of State to clarify what a service provider is. Section 78 deals with the detention of a child in a hospital or other place. I need clarity on this other place. In terms of access, is there a distance from where the family or caregiver is living to this other place? Regarding consent, who gives consent for the child to be in this other place? How is the supported decision-making done in this other place?

Who is notified if something happens in this other place? Could this other place be abroad? Could the Minister of State give us some clarity on this other place and what a service provider is? If it is not the centre, where is the service provider?

I share some concerns. The point Senator Ryan made on clarity is a good point in relation to abroad. I do not think this is anecdotal but there are concerns. I was going to raise this later. There will be another relevant section later on but I will talk about it now and I may talk about it again. Can we categorically say that nobody, be they children or adults, is involuntarily or cared for outside the State in terms of mental health? I do not know what the statistics or the arrangements are. We do know in the past that a number of children, through Tusla or previously the HSE, were transferred to Scotland and places under special care orders for what was termed specialist care. The Senator has triggered that point there.

There is a concern, particularly in the area of mental health, that people would possible be transferred outside the jurisdiction of the State. I do know not if the Minister of State has statistics, detail or anecdotal stuff on that. It is an area of concern because they are now in another jurisdiction and that has knock-on effects. We talked about unintended consequences. We are certainly leaving ourselves open for unintended consequences if that was to happen. I do not have any hard evidence on it. There are suggestions that this has happened, may happen or there has been the threat of it happening. That in itself is not satisfactory. The Minister of State might share with us. I thank the Senator for raising that particular issue of concern.

I am in agreement with my colleagues. I want to know what alternative locations or other place is envisaged under this amendment for a child who has been involuntarily admitted. There is a bit of a concern. If it is, for example, a hospital for their physical health, they may not be in a position to return immediately to the approved centre because their order has expired. In cases where a child has been transferred to another place, the child will be in an approved centre despite being involuntarily detained, meaning that the Mental Health Commission would not be regulating the actual physical environment they are being held in. I want to know what oversight or monitoring of these places will be in place, given the safeguards that apply in approved centres. What input will be sought from parents or guardians in such cases? That is really important. How will the child's views be considered?

I will do my best to answer some of the Members' questions. I thank them for raising them. Amendments Nos. 264 to 268, inclusive, and Nos. 271 and 273 are being discussed together.

Amendment No. 264 provides for a new section 77 of the Bill, which sets out that where the parents of a child to be admitted voluntarily, or their guardian, or Tusla, as appropriate, are unable to bring the child to the registered acute mental health centre for admission, they can request the assistance of the centre to arrange for the transfer. They are being admitted voluntarily, so they are not under an order or anything. This would be very unlikely, to be fair. The centre is the approved centre. We have four approved centres in Ireland in relation to younger people. I assume, when the new children's hospital opens, we will have to amend the Bill to include that.

Amendment No. 265 provides for a new section 78 in relation to the transfer of an involuntarily admitted child where they need treatment in hospital or facility other than the registered acute mental health centre. Take a child who is currently involuntarily detained in an adult facility and who is going to be transferred to another centre. That is what this is allowing for. Where the child needs treatment other than in the "registered acute mental health centre", that refers to the other place we are talking about. It will never be outside the State. That is my understanding. To answer the Senator's question, I stand open to correction but I think I am right on this and we have spoken a lot about this. I refer to Dr. Amir Niazi again because he gives me so much advice and support. He is the clinical lead for all the clinical programmes for under-18s. Since the model of care was introduced in 2018 for eating disorders, no child has had to be treated outside the State.

We all know that there is a treatment abroad scheme that can be accessed for adults, for example. They could be treated abroad, but it may not be in relation to their mental health. You could have a situation in relation to that. When we talk about service providers, these are trained operators. For example, a lot of people live in community residences all over the country. During mental health conditions, these residences will be regulated because of this Bill, which is one of the first pieces I am going to move to do. These are in the care of the HSE.

Sometimes the HSE outsources. Nua Healthcare, for example, is one of the providers. The HSE, as it says to me, is not a landlord but it does have some houses and it leases some houses. I met patient advocacy services this morning. Senator Black will be interested in this. We spoke about national advocacy services and patient advocacy services. Sometimes people who are under the care of disability services have mental health issues as well. They are able to access patient advocacy services at the moment - about 10% of people with mental health issues. It was great to be able to have that discussion today. Service providers are trained operators. Nua Healthcare provides a lot of supports for people with disabilities, as we know, who need one-on-one support. There are also cases where we have some service providers in relation to mental health. I have heard a lot of talk about Kyrie Farm, for example. That is a private provider per se. That is what I am talking about.

In relation to another place, it will not be outside the State. The intention is for children to be transferred to an accident and emergency department or somewhere in the State if they require treatment. It is just so that there will be no doubt in relation to what should happen in a case of a child involuntarily detained in the care of Tusla or the State and, if there was nobody to bring that child to another facility, what the facility is. The facility will always be determined by a clinician to find the best appropriate setting for the child to be looked after. I hope that answers the Senators' questions. I did not quite get them all. If they want to come back to me, they may.

I thank the Minister of State. It gave a little bit of clarity, but in terms of the other place, there is an unintended consequence of it at the moment because it leaves it too open to ambiguity. Who is to say that another place is not just some other place down the road? Essentially, the other place can be interpreted as anything you want. As for the service providers, the Minister of State mentioned Nua Healthcare and Barróg Healthcare. Loads of them provide services but who has the clinical oversight of those services if they are private? We have seen this in a case. As the Minister of State has responsibility for older people, she will know about the privatisation of nursing homes and all the scandals we have seen through that. Who has the oversight of these private providers and service providers that potentially could be Nua Healthcare or the likes? I worry about the ambiguity of the other place. That could be interpreted as any place.

I will follow on from that and talk about amendment No. 267, which is also in this grouping and is the request for the application of the transfer of a child. Amendment No. 267 is a Government amendment. I think there may be a case here for the Minister of State to consider. There is some ambiguity about the approved centre and another place. It sounds like a terrible Walt Disney thing; another place, another story.

We may have put our finger on something here, and it is about improving legislation. Maybe there is potential for strengthening safeguards around this area. This is, after all, primary legislation we are talking about. We want to put in place a robust new Mental Health Act that has time and will withstand many challenges but will put in place strong safeguards.

Again, I reference the Minister of State's amendment No. 267, which concerns a request for an application for transfer of a child and reads "a request may be made to the clinical director of the registered acute mental health centre for the transfer of an involuntarily admitted child detained in that centre to another acute mental health centre". I hear what the Minister of State is saying, that it will never be outside the State, but perhaps we could strengthen the legislation. Could we look at saying under no circumstances - let us be clear about it - will it be provided for a child, particularly involuntarily? I understand people can opt for care for other services, but in relation to this, this is Mental Health Bill. We are not talking about the National Treatment Purchase Fund or cross-border dental treatment or other interventions where you nominate to or seek a referral to by choice. In light of all the sensitivities and about one's current state of mind and who is recommending the options or care plans, it would be of comfort if the Minister of State might at least take it away, consider it and come back with some amendment or change to strengthen the legislation to put safeguarding in place. People move and Ministers come and go with the best will and intention. I do not have the wherewithal, but between the Minister of State, the Parliamentary Counsel and her legal advisers, I respectfully suggest that she take it away and ask how we could strengthen this so that there would be no situation of a child being treated outside the State, particularly involuntarily. The Minister of State has said herself she does not want unintended consequences. We are not lawyers in here but I think that would give comfort and is what people would be concerned about. I ask her to consider the matter.

I have a couple of points. The term "other places" is used in the 2001 Act and there have not been any unintended consequences since then. It is also used in the 2024 Bill regarding adults, so we just kept the same language going.

A registered acute mental health centre is defined in the Bill as only an inpatient service registered by the commission. By definition, it cannot be a transfer to somewhere that is not registered by the commission; that just cannot happen. As I said, any transfer would be for the purpose of giving the child treatment that is not available in the mental health service.

I am here moving a Bill regarding services provided by the HSE. I have told the Senator the HSE has not referred a child under 18 since 2018, when the model of care came in for eating disorders. I cannot tell him whether a family has chosen to bring their child to some place privately, so if we were to legislate that no child would be treated abroad, I could not do it for that reason. Not everybody chooses to use the HSE for their health services. Some people choose private healthcare or choose to go down a different route. I could not close that off.

We spoke about ECT last week. ECT has not been administered to any child here in the past ten years, for example. There is no consultant psychiatrist or CAMHS consultant who is qualified to actually do it.

I will take a look at it. I am going to take it away and have a look at it between now and tomorrow as regards other places, and maybe we will see if it can be strengthened. I looked for the definition there and I could not find it quickly. For me to be happy, I will take it away and look at it. I thank the Senator for raising it. The definitions are there for a registered acute mental health centre. I know everybody wants to make sure there is no unintended consequences, and I appreciate that. I will take it away and I will be back tomorrow. I will look at it, and if it needs to be changed on Report Stage, I will do that.

That is great. Thank you.

Amendments Nos. 276, 277, 281, 282, 286, 288, 290, 291, 295 and 297 are related and may be discussed together by agreement. Is that agreed? Agreed.

In the first instance, I wish to speak to amendment No. 297. This amendment provides for a new section in relation to applications to the family District Court for treatment orders in certain circumstances. This is an important provision and is needed to ensure there is a substitute decision maker in place for children where there is an absence of consent or refusal. For example, an application may be made to the District Court to act as substitute decision maker on behalf of a child where the child is under 16 years of age or is over 16 and lacks capacity to consent or refuse treatment, and where there is either no legal parent of the child in place or where the parent is unable to or fails to make a decision to consent to or to refuse treatment. In such cases, the child would be admitted but there would be no one to make a decision on his or her behalf. Therefore, the child could not be treated or supported to make the care plan we spoke about.

This new section addresses this issue and ensures there are appropriate protections in place for the child and for the parent or guardian of that child. The District Court may act as a substitute decision maker for a limited period and only where there is an absence of consent. This provision cannot be used where there is a disagreement between the parents and the clinician on treatment, and that is really important.

This amendment is absolutely necessary and will ensure children with parents who are unable to consent are not disadvantaged. Officials in my Department discussed this provision with the HSE, including the HSE child and youth mental health office. In some cases, when a child is being involuntarily admitted, they will not be coming from the most stable home environment. Their parents may be dealing with mental health issues themselves, addiction or simply may not be in a position to make decisions about treatment on behalf of their child. The section is being introduced to ensure that, in some cases, children can still be treated.

As I said, this was an issue raised with us. To clarify, it is the District Court which may act as the substitute decision maker for that limited period and only where there is an absence of consent. If the young person can give consent, it does not apply.

I thank the Minister of State for reading that into the record. It shares some of the echoing concerns we have been talking about. There are those cases and, quite frankly, that is the sad reality of it. There are cases in many spheres where no one has an advocate and the Minister of State has identified that. She has provided a good rationale in support of it and that is important. We have not lost sight of it, and I thank the Minister of State for reading that into the record.

I move amendment No. 300:

In page 94, between lines 4 and 5, to insert the following:

“Chemical restraint

88. (1) A chemical restraint shall not be applied in respect of a child receiving treatment in a registered acute mental health centre or designated centre unless—

(a) the restraint is ordered and initiated by a relevant health professional,

(b) the restraint is applied to the child by a relevant health professional or a specified person under the direct supervision of a relevant health professional,

(c) the application of such restraint is determined by the relevant health professional, in accordance with regulations made under section 58, to be necessary where there is an immediate threat of serious harm to the child concerned or to another person, and,

(d) the chemical restraint concerned complies with regulations under section 58.

(2) The Mental Health Commission shall conduct a comprehensive review of the use of sedatives across all psychiatric institutions, with particular attention to the risks of over-medication and the potential use of such medications as chemical restraints. Following this review, the Commission shall develop and issue clear guidelines governing their appropriate use.”.

Amendments Nos. 303 to 306, inclusive, and 309 are related and may be discussed by agreement. Is that agreed? Agreed.

I will speak to amendments Nos. 303 to 306 inclusive and 309, which have been grouped together and relate to restrictive practices on children.

Amendment No. 303 inserts explicit reference to including the "best interests and the welfare of the child" as the primary consideration - we would have spoken about this earlier, Senator Boyhan - along with the guiding principles for children in section 10, in any regulations made by the Mental Health Commission for the application of a restrictive practice for a child in a registered acute mental health centre.

Amendment No. 304 replaces section 90(1), separating it out into two subsections to provide clarity in relation to the notification of the use of a restrictive practice. It is tightening up what we have already discussed.

Amendment No. 305 deletes section 90(3), as this is now included in new section 91 in relation to the role of parents, guardians and Tusla, where appropriate, on the use of restrictive practices.

Amendment No. 306 replaces an incorrect subsection reference.

Amendment No. 309 inserts a new section 91 that provides for the will and preferences of the child - we will have discussed this earlier on - to be taken into account in relation to the use of restrictive practices on children, and that the child and their nominated person, parent, guardian or Tusla, where appropriate, are informed of its use and a record of the child’s views recorded in their medical records and care plan. This provides an additional safeguard where a restrictive practice is being used.

Amendment No. 309 is very positive, in that the centre is required to explicitly inform the child and any other relevant parties about the application of restricted practices, gather views and record those views. However, I have a concern. When a child is 16 years of age or older and in the care of the State, Tusla must also be informed, but when a child is 16 years or older and in the care of parents or guardians, it appears that they do not need to be informed. I want to get an understanding of the reason for that difference in approach. Would it be helpful to make it explicit that any information provided to the child about applications of restricted practices, as required under amendment No. 309, should be delivered in an accessible and age-appropriate manner? Such a measure would strengthen the provision and ensure compliance with best practice and children's rights standards. Is the Minister of State open to considering my proposal?

The Mental Health Act 2001 contained very little information in relation to restrictive practices for children and for adults. Section 69 simply states at the moment, in relation to seclusion and bodily restraint, that such seclusion or restraint can only be carried out in accordance with rules to be made by the Mental Health Commission. A person who contravenes these rules is liable for conviction, and this applied to both adults and children.

As Senators will be aware, the Mental Health Bill 2024 overhauls our approach to the use of restrictive practices and contains many more legal safeguards and protections for adults and children. There are two separate chapters in Parts 3 and 4 of the Bill. The Bill sets out strict criteria that must be made before a seclusion or restraint can be initiated. In relation to children, and this is extremely important, a seclusion or restraint can only be applied where it is in the best interest of the child, in rare and exceptional circumstances, where there is no safe alternative, where it is the least restrictive practice possible in the circumstances, where it is proportionate to the assessed immediate threat of serious harm, for the shortest duration possible. The Bill details who can order, initiate and apply a seclusion or restraint. The Bill also contains information on record-keeping, notification to the commission and to any nominated person, and a requirement to continue to communicate with the person the subject of the restraint or seclusion. Importantly, any use of seclusion or restraint must comply with regulations made by the Mental Health Commission. The following is really important. Where a person contravenes the provision of the Act or a regulation in relation to a restrictive practice, he or she is liable to be convicted.

Share the Vision includes a recommendation to adopt a zero seclusion and zero restraint approach in mental health services. As I outlined last week, there has been a significant reduction in the usage of seclusion and restraint in mental health services. According to the Mental Health Commission, so these are not my words, Ireland ranks among the lowest in comparable countries for the use of seclusion and restraint.

The use of seclusion and restraint must always be accompanied by very strong legal safeguards, particularly so when it comes to a child. The Bill provides for that. Comparing the contents of the 2001 Act and the contents of this Bill, I think we have really strict criteria now.

When the Bill details who can order, initiate and apply a seclusion or restraint, that goes a long way. When a person contravenes the provision, he or she is liable to be convicted. That is extremely strong. It is an area that we have not discussed much. We are just coming to the latter end of the Bill now. This was a piece that needed to be included. A lot of work has been done on this particular section to make sure that it is right. It is much stronger than what we had previously.

That is all positive. I am happy to hear that. When a child is 16 or over and in the care of the State, Tusla are informed but when a child is 16 or over and in the care of the parents or guardians, it appears that Tusla does not seem to be informed. I would like some clarity on the reason for the difference in approach.

The Child Care Act does not differentiate between children under 16 and over 16. That is the important piece. That is why Tusla must be informed regardless of age. In relation to children over 16 coming from family homes, parents will be notified if it is in the best of the child. The Department is continuing to refine notification provisions before Report Stage. This is a complicated piece of the Bill. A lot of work is going on in the background. I met with the Office of the Parliamentary Counsel, OPC, at 2.30 p.m. today to discuss certain elements of the Bill that are still live. We will certainly consider the Senator's suggestion. We will engage with her on what she has asked for before we get to the notification provisions, which will be discussed on Report Stage. To flag it for the Senator's diaries, if we can have the agreement of the Seanad in relation to its diary, we will be looking at the week when we come back on 18 March after St. Patrick's Day if that is possible. We need about four weeks to get this piece of it sorted.

For the benefit of Members, it is a Government amendment. The acceptance of this amendment involves the deletion of section 91. While it says that a new section will be inserted, the amendment providers the deletion of the section.

Amendments Nos. 310 and 314 to 318, inclusive, are related and may be discussed together by agreement. Is that agreed? Agreed.

These amendments are typographical and insert the word "the" where required. Amendment No. 316 replaces an incorrect subsection reference. Amendment No. 317 corrects the definition of "committee of inquiry" to add that it is for use of section 335 only. Amendment No. 318 replaces the term "the inquiry" with "carrying out an inquiry". They are all typographical. They are all related to wording.

Amendments Nos. 311 and 312 are related and may be discussed together by agreement. Is that agreed? Agreed.

I move amendment No. 311:

In page 112, between lines 4 and 5, to insert the following:

“(d) the progress towards and resource requirements for the extension of CAMHS towards a CYMHS for young people up to the age of 25, and the development of youth mental health clinical specialty,

(e) the estimated number of whole-time equivalent clinicians to fully and safely staff public mental health services, and

(f) the estimated level of new additional funding required to provide full and safe services with timely access to care.”.

This amendment relates to one of the most important areas of mental health, which is the disconnect between legislation, service demand and the actual resources required to deliver safe care. We heard from different organisations on CAMHS and CAMHS services at this morning health committee meeting. I am sure the Minister of State has heard pieces herself. One thing they did not dispute was that there is legislation there. There are plans. That is all well and good. It is the implementation that is taking a long time. We all recognise that implementation does take a lot of time. The problem is that families are not seeing the implementation fast enough for some of their children. They fall through the cracks. When we look at the Bill, it sets out an ambitious reform agenda. That is down to the Minister of State. However, when we have ambition without workforce planning, it is not reform because we cannot legislate for new rights, services and clinical models without also legislating for how many clinicians are required, how much funding is needed and how long it will take to implement it.

This amendment ensures the Minister of State will report progress towards extending CAMHS into a full CYMHS model up to the age of 25, the development of a youth mental health clinical speciality, the number of whole-time equivalent clinicians required to safely staff services and the amount of new additional funding needed to deliver timely access to care. If we do not have this information, we legislate in the dark. Every Member of this House knows the reality of CAMHS. We hear it all the time. The transition from CAMHS to adult services is one of the most dangerous gaps in our mental health system. Young people do not suddenly become emotionally stable at the age of 18. Their vulnerability does not end on that birthday. That is why international best practice is moving towards a CYMHS model up to the age of 25. This amendment ensures the extension of CAMHS into a CYMHS model. It is not just talked about, but properly planned, costed and delivered. As the Minister of State knows best, young people have distinct clinical needs. This amendment requires the Minister of State to report on the development of youth mental health clinical speciality. It is something that clinicians, academics and service users have called for.

Amendment No. 312 is about the rights of the service users and their families to raise concerns and to know those concerns will be heard, investigated and acted upon independently. We briefly touched on this throughout the debate. We feel that this is a necessary safeguard. Without a credible complaints system, rights only exist on paper. We ask people at their most vulnerable to trust the mental health services with their liberty, autonomy, dignity and sometimes even their lives. The trust must be earned, but it also has to be protected. Yet we know from service users, families, advocates and clinicians that the complaints processes are often confusing, inaccessible, slow, poorly communicated or not available at all. Many people simply do not complain because they fear repercussions or because the process feels intimidating and futile.

That is really not acceptable in a healthcare system, particularly in one that has coercive powers. Complaints are not a problem to be managed; they are really an early warning system for us. They tell us that patients feel unsafe and where dignity has been compromised. The amendment places the responsibility on the Mental Health Commission, the statutory regulator for mental health services. It requires it to examine the quality of the existing complaints process, to assess its independence and make recommendations to strengthen that. That is exactly where this work belongs. We need a national independent assessment of how complaints are handled across the system. The 12-month timeframe is deliberate. It ensures that there is no drift and that it is prioritised. If we are modernising mental health law, we must modernise accountability at the same time. Public trust depends on accountability. The legitimacy of any mental health system depends on public trust. When people believe their voices will be ignored, they disengage. When families fell powerless, trauma deepens and when staff have no safe way of raising concerns, that risk escalates. A strong independent complaints system is for everyone and this amendment just legislates for that.

These are very important amendments. A report examining the existing complaints process and setting out recommendations for strengthening it as requested under amendment No. 312 would be really welcome. I have a later amendment around the need for an independent complaints process. At present, the HSE's Your Service, Your Say mechanism functions only as a basic service-level feedback tool. It was repeatedly raised to us during the pre-legislative scrutiny that there is a need for a direct complaints mechanism in relation to mental health treatment that is entirely independent from the current internal HSE complaints mechanism. The Mental Health Commission, as quoted in the pre-legislative scrutiny report, stated:

There should be a culture of complaining being a good thing, [which I think is really important] because that is how you improve the system. The advocates would help people to complain when they need to.

An independent mechanism is all the more important in mental health settings, given that persons using mental health services are at increased risk of coercion and restriction of their human rights. Ultimately, the subcommittee recommended the establishment of an independent, fully funded and resourced complaints mechanism for mental services because there is no other cohort of people accessing health treatment who may be denied their liberty. This was something our good friends Dr. Fiona Morrissey and Dr. Charles O'Mahony strongly called for in their human rights analysis of the draft heads of Bill in collaboration with Mental Health Reform. Dr. O'Mahony said in a recent audiovisual room briefing that independent advocacy and an independent complaints mechanism are two of the most basic safeguards for people involuntarily detained in mental health services and that an independent complaints mechanism would allow for systemic learning and prevent reoccurrence of problems. Without these safeguards, we risk continuing a culture where people feel powerless and unheard in the system that is meant to support them.

I also want to turn briefly to the case of Juanita, whose story I read out in a recent debate. The House will recall Juanita asked several times for information on how to make a formal complaint. She was never given a complaint form, email address or clear guidance. Instead, she was told to write her concerns on a piece of paper. She did so but no one read it or followed up with her and she felt completely ignored, silenced and powerless. The powerlessness is really difficult. It must be awful when you are feeling like you are in a powerless place. That is not acceptable. I may also speak to this later when discussing my own amendment but I heard in the audiovisual room of mothers with lived experience trying to make a complaint. Again, what we heard was really unacceptable.

I will provide a few reasons an independent complaints mechanism is so necessary. When people feel safe to raise concerns and know they will be heard, it fosters trust in services and supports recovery. I know that through my own work with the RISE Foundation. An independent complaints process can identify systemic issues early, leading to service improvements and better outcomes for individuals and communities. People with lived experience and their supporters often report fear of retaliation or a sense of futility when raising concerns within the same service that provides their care. An independent complaints mechanism would provide a safe, impartial route for redress, ensuing all voices are heard and protected. I know the Mental Health Commission provides overall oversight of approved centres but does not really investigate individual complaints. The HSE's Your Service, Your Say functions as a service-level feedback system offering an accessible first point of contact for comments and resolutions. While those who are involuntarily detained have a review board tribunal hearing, this hearing only reviews the appropriateness of the involuntary admission order. It does not properly examine other aspects of care, including involuntary treatment decisions.

The recent deeply troubling revelations from Bloomfield Hospital underscore the urgent need for an independent complaints mechanism in mental health services. That is a perfect example. Despite receiving a 94% compliance rating from the Mental Health Commission for three consecutive years, serious and systemic abuse of residents was uncovered at that facility. The stark disconnect between regulatory compliance scores and the lived realities of patients highlights the limitations of current oversight mechanisms. I feel for Juanita. If only she could have been heard that time, it could have changed everything for her. She went in voluntarily. She volunteered herself in but under the circumstances it was just horrific for her. I thank the Minister of State and appreciate her being here.

Before I call on Senator Boyhan, I welcome Deputy Paul McAuliffe and students from Dublin City University who are here for the debate on the Mental Health Bill and to listen to Senators and the Minister of State.

I will be brief because I have mentioned this before. Senator Black has touched on it there again. We should have an independent commission, an independent process and a complaints procedure. We all know what happened in Bloomfield Hospital. I give a call-out to Shauna Bowers, the health correspondent in The Irish Times, who covered this story extensively over the Christmas period on the litany of abuse that took place in the Bloomfield supposed care centre. It is all documented. We have discussed it here with the Minister of State in every session since Christmas. The commission gave the hospital a 94% clearance rating three times in a row. There is no dispute about that. It is shockingly scary what has happened there. We need this independent complaints procedure. There were whistleblowers in there who told the story and who engaged with the journalists, particularly Shauna Bowers. That is how that story evolved but she then went on to investigate it further. There is no dispute about what happened there. I think there is to be an investigation; I will keep pressing for it. I was considering drafting some parliamentary questions but I will not bother because I feel I can now talk to the Minister of State directly. Some people will give the usual response to questions. If it is a HSE thing, they will send it out. One of the shames now when we look at our Dáil reporting is that we see comments such as "the HSE will write to you directly". This cuts out and short-changes the public who want to look in and see the responses. I have written to a few TDs today asking them to post their responses when they get them and to engage. It is important that we have oversight and that we look in. I do not like to see a situation evolve in any parliamentary process where suddenly it is all watered down and Ministers are feeling they have to tell us, from all these quangos we have around the country now, that they will write to us directly. It bypasses the parliamentary scrutiny and questioning. However, that is another day's work.

Based on Bloomfield Hospital alone, there is a very strong case for an independent complaints process so that the workers at all levels within the provision of the service and the people who have had direct experience will have the confidence externally of the other processes. It is not to have to invalidate them. Any concern has to be validated. There is a strong case for it. I am pleasantly surprised this amendment got in. I would have thought it might have been suggested it would incur a cost to the State. I have been told I could not have a report because it is a cost on the State and I stand up in here saying we are all in here on the payroll and we are all a cost to the State. It seems to be different arrangements for different days. I will leave it at that.

I will speak to both amendments. They have been grouped together because the commission is mentioned, but they are quite different so I will speak to both of them individually, if that is okay. First, in relation to the Senator’s amendment, this was presented on Committee Stage in the Dáil and I have looked at it, but my position remains unchanged and I will tell the Senator why. I do not think it is appropriate for primary legislation. The commission is independent in its functions, and I would have concerns about dictating in primary legislation what the commission must include in its annual report.

Second, the commission is not responsible for implementing mental health services. It would be inappropriate for the commission to be responsible for estimating the required number of staff members or funding in mental health services. We do not ask HIQA to do that, for example.

It is important to look at what exactly the role of the commission is. The role of the commission is to regulate mental health services, including the inspection of mental health services, promote the improvement of mental health services by setting standards for best practice in those services, encourage adherence to those standards, promote public awareness of the regulation of mental health services and other matters provided for under this Act, and take all reasonable steps to protect the rights and interests of persons detained in registered acute mental health centres. It is not the role of the commission to deliver services or to dictate how State resources should be allocated. The allocation of State resources is solely the responsibility of the Government of the day, made up by the elected Members of the Oireachtas. It would be entirely inappropriate to place the responsibility of delivering services and-or allocating State resources on the Mental Health Commission. It just would not be possible.

I have a very good working relationship with the Mental Health Commission. I have had my disagreements with it as well, let me tell you, over the past five years, as have my officials in the Department. However, in relation to CAMHS, I wrote to the commission last year, when the Bill was going through the Dáil, to request that it begin working on developing national standards that will apply to child adolescent mental health services. The work is already under way, and the commission has formed a working group and is actively working towards delivering the standards this year. The standards will help inform the future regulation of community camps. That is the complete independence of it. It is doing that at the moment. Members will actually have seen that the organisation reached out on social media looking for people who have had experience of having their child in CAMHS or who have been in the care of CAMHS themselves. They could be involved and there is an opportunity for them to make a submission to that.

Regarding the reference to CAMHS in this amendment, CAMHS is not defined anywhere in the Bill, nor are the child and youth mental health services, CYMHS. I would not be in a position to start putting it in now. In relation to what we are trying to achieve, I visited 21 CAMHS teams just before Christmas. For about six months, I took to the road and travelled all over. I am trying to understand why some CAMHS teams are performing extremely well. We have approximately 770 people working in CAMHS. We have 80 consultant psychiatrists, clinical psychologists and multidisciplinary teams all over the country. However, when we compare and contrast CAMHS teams, I have to give a shout-out to Limerick, for example, which has just done an unbelievable job of turning it all around and now holds 3.5% of the waiting list in the whole country. Limerick reduced its over 12-month waiting list by 89% and its up to nine months waiting list by 59%. Limerick has eight CAMHS teams in that particular area. Other areas have more, but with a dedicated focus led by a consultant down there, Dr. Eithne Foley, it has managed to turn the whole situation around, working closely with the regional executive officer in that area. We need to give good practice a shout-out as well.

I travelled to Donegal for a full day and met with all those providing mental health supports there. I was extremely struck by the way the three CAMHS teams work together and by the fact that I was located in one area and the clinical director from the department of psychiatry came to meet me. Three GP left their practices to come to meet me. They are all pulling together. Their ask was for a crisis resolution team in Donegal and a Solace café. I provided funding of €1.3 million this year to deliver that on what we call the peninsula, because it is so far removed from an awful lot of services. I was struck by the way they all work together.

I visited CAMHS teams that are located in the most beautiful primary care centres, with 16 or 17 members of staff, with the highest waiting lists in the country, and not the highest catchment areas. I am trying to get under the bonnet of how some CAMHS teams perform extremely well. I cannot understand how we can then have teams that are not doing well, and while I do not want to start saying where they are, anyone can look at the data. I was very struck after the Maskey report, when I asked the Mental Health Commission and the HSE to do an independent audit and review, that an awful lot of the CAMHS teams work in independent silos and are not supporting each other, even in the same counties. I did not see that in Donegal or Limerick but I have seen it in other areas. I visited one particular facility where one CAMHS team was only accepting emergencies and another CAMHS team had capacity. I actually asked for one team to support the other and I did not get a positive outcome. That is the reason I travelled.

As I said, I will be issuing a report on it to the HSE to let it know the reasons I am disappointed and reasons I am pleased. Lucena in the Kildare area is doing an absolutely phenomenal job. All the teams get additional funding to try to manage their waiting lists, especially those over 12 months. What I was really pleased with was they were doing dialectical behavioural therapy, DBT, with families, and the whole family was included in supporting the young person. I have seen really good practice, and it is not fair to say we have not. We also have to appreciate that the additional referrals that we have seen to CAMHS teams in the past five years have been unprecedented. The population has grown. We had a situation back in 2016 or 2017 where we had 900,000 young people in Ireland and we now have 1.2 million. That is an increase of 20%. Services are going to be under pressure. I digress but I just thought it was important to put it on the record that we have a huge amount of really good work happening. Children are presenting with more complex needs and they are a lot longer in services than they used to be. Previously, when a child came into a service, another child was leaving. That is not the case anymore, and that is why waiting lists are always inclined to go up over the winter period. I do not know for what reasons they always fall during the summer, but it is one area I am keeping a close eye on.

In relation to amendment No. 312, and Senator Black spoke to this as well, I do not believe this requires an amendment in primary legislation. It is not appropriate to dictate what the commission carries out in this report. If it is a requirement as part of the pre-commencement work on the Bill to research existing complaints, procedures and services, I will direct officials in my Department to look at this as part of the commencement plan. The Bill strengthens the requirement that people receiving treatment in a registered acute mental health centre be given information in relation to the complaints procedure in the centre. That is in the Bill. This is true for both involuntarily and voluntarily admitted people.

The 2006 approved centre regulations include a regulation related to a complaints procedure. These regulations will be replaced under the new enactment, and I expect significantly more detail in relation to complaints procedures will be included in the new regulations. The regulations will be comprehensive and will deal with how complaints have been made. The Department will also look at advocacy that can be provided. As I said, I met with patient advocacy services this morning. I want to see it rolled out as soon as possible. However, we cannot lose sight of the fact that the Bill also requires that every admitted person must be given information about the services complaints mechanism.

Regarding Your Service Your Say, I have dealt with people who have had a good outcome from it and many who have not. At the same time, that is the system we have across the HSE at the moment, and there is an awful lot that we are going to deal with in secondary legislation. I will not be found wanting in doing that.

I am glad to hear the Minister of State has hit the road and is visiting the various CAMHS teams, because to acknowledge that there is a disparity between certain CAMHS teams is very valid.

Today, in the health committee, one thing that struck me was that Jigsaw said that some CAMHS teams do not accept referrals from it, but others do. That is wrong. It is almost a postcode lottery as regards where accepts referrals. I was not aware the Minister of State had hit the road on it, but I am happy she has and I am glad she acknowledged the differences, because it shows we can achieve change.

Is the amendment being pressed?

Yes.

I move amendment No. 312:

In page 112, between lines 21 and 22, to insert the following:

“(3) The Commission shall within 12 months publish a report on the quality and independence of complaints processes and make recommendations for the strengthening of such processes.”.

Before we move on, can I ask a quick question? Would it be possible for us to come in slightly earlier and start at 12 noon tomorrow? A break is scheduled.

The Leader can bring it up on the Order of Business tomorrow.

I can come in.

It needs to be agreed.

Amendments Nos. 313, 330 and 331 are related and may be discussed together by agreement. Is that agreed? Agreed.

I move amendment No. 313:

In page 116, line 14, to delete “a consultant psychiatrist” and substitute “a qualified mental health professional”.

This amendment proposes a simple but important change, namely, to replace the phrase "a consultant psychiatrist" with "a qualified mental health professional". It is not about downgrading standards but reflecting the modern clinical practice of multidisciplinary care and the reality of the workforce shortages. We all know consultant psychiatrists are in critically short supply. Across the State, there are long-standing vacancies. Posts cannot be filled and services are operating without permanent consultants and with an over-reliance on agency staff. That creates two serious problems, bottlenecks in care and delays in access to service for patients. If the law says that only a consultant psychiatrist can carry out a practical function, when no consultant is available, the function simply cannot happen no matter how urgent the clinical need is.

Modern mental health services are not consultant-led in isolation. Mental healthcare is delivered under multidisciplinary teams. As the Minister of State will be aware, there are psychologists, psychiatric nurses, social care professionals, occupational therapists, psychotherapists and many other specialist clinicians. These professionals are highly trained and highly regulated and already carry out many of the assessments, interventions and care planning functions across the system. This amendment recognises that reality. It allows appropriately qualified mental health professionals to exercise statutory functions within their scope of practice rather than creating artificial legal barriers that slow down care. It ensures that where qualified professionals are competent to perform a function, they are not prevented from doing so by outdated or overly rigid legislative drafting. The standards remain high, but access becomes faster. Internationally, mental health legislation is moving away from narrow, doctor-only led models towards multidisciplinary, team-based care.

As Senators may be aware, a consultant psychiatrist is the only person who can make an order to detain someone involuntarily under the Mental Health Act. It is a huge responsibility and must only be done as a last resort. When a person is under the care of a consultant psychiatrist, that psychiatrist is responsible for that person and has legal responsibility for their care and treatment. This means the psychiatrist is the person who is liable for the person receiving treatment. Considering the central role of psychiatrists in the involuntary admission of people to inpatient mental health services and the central role of psychiatry in mental health services, it makes sense that the clinical director of an inpatient mental health service be a consultant psychiatrist and that the chief inspector of mental health services continue to be a consultant psychiatrist. I was not aware we were in critically short supply of consultant psychiatrists. We have some vacancies, but it is not an issue the Irish College of Psychiatry has raised with me.

I cannot support amendments Nos. 313, 330 and 331. A responsible consultant psychiatrist is required, as the role demands the clinical expertise, medical knowledge and independent judgment necessary to inspect and report on the quality of mental health services. A consultant psychiatrist is a fully qualified and experienced medical doctor who specialises in diagnosing and treating mental illness. That is the necessary authority and perspective for the role.

It may be that there can be circumstances in community settings but that would certainly not be the case in an inpatient facility.

As it is 7 p.m., the debate is adjourned in accordance with the order of the House today. The Minister of State will be in possession when we resume tomorrow.