RQIA Independent Review of The McDermott Brothers' Case

8.0 Conclusions and Recommendations
8.1 In examining the detail of the WHSCT's involvement of this case, RQIA
acknowledges that the issues being dealt with were complex. It is
evident that the WHSCT has duties that span a range of statutory
functions. These relate to the provision of care and protection of the
population within its geographical boundary, and also a duty for the
care and treatment of individuals identified to them as having a mental
disorder or learning disability.
8.2 In ensuring that the terms of reference for this review have been
properly addressed, RQIA examined in detail the full range of clinical
and care records of the brothers; the full range of management
communications and directives with the service; and, communication to
and from other agencies and organisations associated with the case.
This information was further validated through interviews with the range
of WHSCT officers involved in the case.
8.3 Key to understanding the many complex issues arising out of the case,
the views of survivors were also sought on their perceptions and
experience of the care, support and communication from the WHSCT.
8.4 RQIA assessed that the WHSCT has met the requirements of relevant
legislation and policy in its supervision, care and treatment of James
Francis and Owen Roe McDermott, and its governance and
management arrangements relevant to the case.
8.5 With regard to child protection, RQIA concluded that the WHSCT acted
within the legislative framework governing child protection. In
recognition of the distress caused to those associated with the case,
the Gateway team discharged its statutory responsibilities around child
protection in a sensitive and empathetic manner. This included a
strategy for engagement with the community on strategies for child
protection. A specific issue was identified in relation to the assessment
of child protection risks in a relevant area of organised social activity. A
recommendation has been made on how this should be addressed in
the future.
8.6 One area for improvement was noted to have been the potential for
vital communication to be lost due to difficulties in communication
between social services and education during school holidays. As a
result, a recommendation is made to address this issue on a regional
basis.
8.7 RQIA considers that, in general, the WHSCT contributed appropriately
to the PPANI arrangements in this case, through the work of the
WHSCT's Principal Officer. An initial lack of awareness of the role of
the new PPANI arrangements across the organisation did not impact
on the response of the organisation to the PPANI process. A
recognised need to ensure effective collaboration in this case after the
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