Clinical Governance Measures Summary

Governance Measure	2012	2013	2014	2015	2016
Clinical Audits	25	19	10	16	26
Number of Complaints	608	635	627	666	860
Total including all complaints, comments and suggestions received and processed throughout the entire year.
Number of Incidents	1,707	2,098	2,227	2,423	2,605
An event or ciscumstance that could have or did lead to unintended/unexpected harm, loss or damage or deviation from an expected outcome of a situation or event.
Root Cause Analyses & Focused Reviews commenced	5	6	11	9	3
A thorough and credible examination of a critical incident in order to determine whether systemic or organisational factors contributed to the occurrence of an incident.
Number of Section 23’s – Involuntary detention of a voluntary service user	94	107	107	92	84
A person who is admitted voluntarily may be subsequently involuntarily detained by staff of the Approved Centre (SPUH) - where the person indicates an intention to discharge from the Approved Centre but following examination is deemed to be suffering from a mental disorder. Section 23(1) allows the Centre to detain a voluntary person for a period not exceeding 24 hours for assessment.
% Section 23’s which progress to Involuntary admission (Section 24 - Form 13 Admissions)	46% (43)	37% (40)	43% (46)	44% (41)	48% (41)
Following Section 23 an examination by the Responsible Consultant Psychiatrist and a second Consultant Psychiatrist the person may be ultimately detained for ongoing treatment and care (Section 24) for up to 21 days.
Number of Section 14’s – Involuntary Admissions	35	46	52	39	60
An involuntary admission that occurs as a result of an application from a spouse or relative, a member of An Garda Síochána, an Authorised Officer or a member of the public and a recommendation from a GP (the person is admitted as involuntary). A person subject to such an admission may decide to remain voluntarily.
% of Section 14’s which progress to Involuntary admission (Section 15 - Form 6 Admission)	86% (30)	76% (35)	80% (42)	87% (34)	88% (53)
Where a service user, under Section 14 admission, does not wish to remain voluntarily and is deemed to be suffering from a mental disorder following assesment, that service user can be detained involuntarily for ongoing treatment and care (Section 15) for up to 21 days.
Number of Section 20/21 - Transfers	8	21	13	19	18
Where an involuntary patient is transferred to an approved centre under Section 20 or 21 of the Mental Health Act 2001, the clinical director of the centre from which he or she has been transferred shall, as soon as possible, give notice in writing of the transfer to the MHC on Statutory Form 10.
Assisted Admissions	22	33	37	18	15
The number of instances where assisted admissions services were required to assist in the transportation of a service user
Number of Section 60 – Medication Reviews	5	15	11	10	4
Where medication has been administered to an involuntary patient for the purpose of treating their mental disorder for a continuous period of 3 months, the administration of that medicine cannot continue unless specific consent is obtained for the continued administration of medication or, in the absence of such consent, a review of this medication must be undertaken by a psychiatrist, other than the responsible consultant psychiatrist.
Number of Section 19 – Appeal to Circuit Court	5	6	2	2	0
A service user has the right to appeal to the Circuit Court against a decision of a tribunal to affirm an order made in respect of him / her on the grounds that he / she is not suffering from a mental illness.
Number of Tribunals held	72	96	91	63	72
Mental Health Commission Reporting – Number of ECT Programme’s (Signed off) in 2016	119	129	143	103	142
Mental Health Commission Reporting – Number of Physical Restraint Episodes (SPUH + WGAU)	157	219	129	178	174