Statement by Minister Mary Butler on the North Kerry CAMHS Lookback Review
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From: Department of Health
- Published on: 18 February 2026
- Last updated on: 18 February 2026
Minister for Mental Health, Mary Butler has today updated Government colleagues on the report of the North Kerry Child and Adolescent Mental Health Services (CAMHS) Lookback Review (NKLBR). The report of the review is now available on the Health Service Executive’s (HSE’s) website.
The Lookback Review was initiated by Minister Butler following the publication of the CAMHS Area A / South Kerry Lookback Review (Maskey Report) in 2022. The North Kerry review involved the examination of all clinical files (374) of children and young people attending the North Kerry CAMH service on 21 November 2022. Of the 374 files reviewed, the potential for harm was identified in 209 files, of which 197 met the threshold for Open Disclosure. All 197 children, young people, and their families, have been contacted by the HSE, offered Open Disclosure meetings, and provided with the supports of a clinical liaison team to meet their needs.
Speaking following publication of the report, Minister Butler said:
“My priority today, as it has been since I initiated this Lookback Review in 2022, is the children, young people and their families. Today will be a difficult day for them, as they will be looking for answers to questions they have had for a number of years. Throughout this process I have been determined that the families are communicated with first and supported as much as possible.
“The families received the report earlier today and I briefed Government colleagues on the report at the Cabinet meeting this afternoon, including the apology from the HSE for the harm caused to these children and young people.”
Minister Butler received the report of the Lookback Review on 6 February 2026. The report raises serious issues of concern which have been considered by the Minister, the Department of Health and the HSE, at a regional and national level. HSE South West accepts all of the recommendations in the report and has, in conjunction with the HSE National Child and Youth Mental Health Office (CYMHO) ensured they are already being implemented across services in North Kerry. Minister Butler is satisfied that all immediate concerns raised within the report have been addressed as a matter of priority.
Minister Butler added:
“I would like to thank Dr Halpin and her team for undertaking this Lookback Review which gave each child and young person a thorough, consistent, and robust assessment of their care and treatment in the North Kerry CAMH service. I appreciate that the review process took longer than expected, but it was important that time and care be taken to ensure the experiences of young people and their families were listened to, taken into account, and acted on.
“I am seriously concerned that such a significant shortfall in standards in the North Kerry CAMH service constituted a risk of harm to children, However, I am satisfied that throughout the review process, and with the findings and recommendations from the South Kerry review, HSE South West has taken the necessary steps to address the deficits in care experienced by children and young people as highlighted in this report and in the Maskey review. It is important to state that with increased governance, regular care and prescribing audits, standardised practice and a dedicated workforce, I am assured that the service now is significantly improved.
“I am also assured that the necessary safeguards have been put in place to ensure that similar risks do not happen again. Throughout the Lookback process all young people and families have had access to on-going support, including the open disclosure helpline and a Clinical Liaison Support Team. My absolute objective in completing and publishing this review was to keep the best interests of young people and their families to the fore.”
North Kerry CAMHS has introduced new Standard Operating Procedures (SOP), care planning policies, file systems, prescribing guidelines, and strengthened physical health monitoring since 2022, ensuring full alignment with national standards. The independent prescribing audit and the 2023 thematic review by the Chief Inspector of the Mental Health Commission did not identify any similar concerns relating to prescribing practices in CAMH services outside of Kerry.
Minister Butler said:
“This report has identified fundamental care deficits in North Kerry. These have not been identified elsewhere in our CAMH services across the country, as outlined in both the independent national prescribing audit and the review by the Mental Health Commission following the Maskey report.
“I want to reassure the young people and their families in North Kerry impacted by this review, that it is my intention to extend to them, the non-adversarial compensation scheme that is in place for families impacted by deficits in care in South Kerry. I have spoken directly to the Attorney General in relation to this and the Department of Health will now progress this with the Attorney’s Office and the State Claims Agency.
“I also acknowledge the HSE's intentions to carry out a clinical review of files of young people who accessed North Kerry CAMHS services over a clinically defined period, who have either a diagnosis of intellectual disability, or who were prescribed antipsychotic medication, or who received high dose psychotropic medication during their care and treatment.”
As part of Minister Butler’s progression of new mental Health legislation, the Mental Health Bill is nearing completion in the Oireachtas. The Minister has already written to the Mental Health Commission to request it begin the process of developing quality standards to regulate CAMHS in advance of the enactment of the legislation. Minister Butler has now directed this report is shared with the Mental Health Commission to ensure the recommendations are considered in the development of standards.
Minister Butler added:
“I am determined that we constantly strive for improvements to deliver the best quality mental health care for children and young people. The CYMHO Action Plan for 2025-2027 will ensure we continue to deliver improvements in North Kerry and across the country.
“Since 2022 I have also funded and prioritised a national clinical lead and regional clinical leads for CAMHS and in December a revised set of clinical operating guidelines was published. I am determined that the best possible clinical governance is in place and constantly reviewed and updated to ensure that the failures in care are not repeated.”
Government under the leadership of Minister Butler will continue to prioritise the quality and improvement of mental health services for young people Investment in mental health services has increased by over 50% since 2020, to almost €1.6 billion this year. An additional 300 whole-time-equivalent (WTE) staff have been allocated to mental health services in 2026. An unprecedented €190 million is provided to CAMHS annually. This is an increase of almost 40% since 2023. In addition, approximately €127 million is being provided to community-based mental health organisations this year, with a significant proportion of this dedicated to supporting child and young people.
Minister Butler concluded:
“I will be in Kerry tomorrow to meet with some of the children and their families who have received an open disclosure apology. I will also meet with the hard-working CAMHS staff in North Kerry, many of whom are new to the service and who have contributed to the significant service improvements since 2022. I wish to stress that any young person or their family in Kerry, or elsewhere, should continue to seek help without delay from our specialist CAMHS service which benefits so many young people and their families each year.
“I fully appreciate the tremendous work being carried out each day by all CAMHS staff nationally to ensure that this key service is safe, accessible, child-centred, and delivered to the highest possible standards. This, along with the need to improve access to care and reduce waiting lists, has been the core objective of the many service improvements initiated by me and the Government over recent years.”
Notes to Editors:
Minister Butler notes that all individuals who wished to engage in the Open Disclosure process were given the opportunity to do so and that these meetings have now concluded. During each Open Disclosure meeting, an apology on behalf of the HSE was offered to the young people and their families for the upset and distress their individual review findings caused. To support families throughout the Open Disclosure process, the HSE established a dedicated Clinical Liaison Support Team to provide independent clinical guidance, signposting, and coordinated follow-up. A CAMHS telephone information line was also set up and remains in operation. The Department is currently engaging with the State Claims Agency (SCA) to clarify next steps needed regarding a compensation scheme.
There have been targeted actions progressed specifically in North Kerry including:
- The recruitment of a permanent Consultant Clinical Lead to provide stable clinical governance and leadership.
- The appointment of Senior Psychologist and Assistant Psychologist posts to rebuild specialist therapeutic capacity.
- The recruitment of additional MDT staff to address gaps in skill mix and reduce reliance on medication-only models of care.
- The development of formal induction, supervision and competency frameworks for NCHDs and MDT staff, supporting professional development and retention.
- Strengthened governance structures and clearer reporting lines, creating a more supportive and accountable working environment.
- Improved communication with Children’s Disability Network Team (CDNT) particularly for young people with Intellectual Disabilities and neurodivergence.
- Implementation of the Individual Care Plan (ICP) Policy.
- In June 2025, following several months of development, Bernard Gloster, CEO of the HSE, directed that the single point of access be implemented across all HSE Regions.
At HSE National Level, progress to improve CAMHS includes:
- A national prescribing audit in CAMHS.
- The development of national prescribing protocols and guidelines.
- The revision of the HSE CAMHS Operational Guideline (COG) in December 2025 to improve operational practice of CAMHS teams, support consistency of service delivery throughout the country, and to build on the existing good practices already in place.
- The rollout of a dedicated electronic health record (EHR) system across all community and inpatient CAMHS.
- Work is also progressing towards the publication and launch of the Integrated Model of Care for Child and Youth Mental Health Services in Ireland by Q2 2026. This will ensure more integrated, collaborative and comprehensive care.