“It is routine to see people who have attempted suicide in police custody or prison cells,” said Prof Gautam Gulati, adjunct professor of Law at University College Cork, reflecting the reality for people suffering from severe mental illness when they come into contact with the law.
Gulati, who has experience in forensic psychiatry, was addressing the Oireachtas Joint Committee on Disability Matters in May, 2024. “In my clinical experience, one in 10 prisoners now require secondary or tertiary mental healthcare,” he said. “In my practice, I regularly come across people with dementia, brain injury, developmental disability and severe mental illness. This includes people with life-threatening conditions such as catatonia.”
A report, Delivering Custody Services (Garda Síochána Inspectorate 2021), found that one in four people in Garda custody over a 12-month period (July 1st, 2018-June 30th, 2019) had “poor mental health” or had engaged in self-harm. Moreover, the inspectorate concluded that more than 2,000 adults and 60 children were taken into Garda custody under section 12 of the Mental Health Act 2001 during the period studied.
Section 12 gives a member of An Garda Síochána the power to take into custody a person who is suffering from a mental disorder, and as a consequence, is likely to cause immediate and serious harm to themselves or others. Once a member of the public is arrested under section 12 of the Act, a garda can make an application to a GP to involuntarily admit them to a psychiatric hospital.
READ MORE
A mental disorder under the Act is defined as mental illness, severe dementia or significant intellectual disability.
A lack of adequate resources in emergency mental healthcare in Ireland means that gardaí are often the first port of call for a mental health crisis. According to the 2024 Annual Report from the Mental Health Commission, almost a third of applicants for involuntary admissions from the community in 2024 were made by a member of An Garda Síochána.
The Community Access Support Team (Cast) in Limerick, established last year, is a direct result of one of the recommendations of the 2018 report by the Commission on the Future of Policing, which, along with a 2009 report from the Mental Health Commission, recommended the establishment of Crisis Intervention Teams (CITs).
The development followed engagement between An Garda Síochána and the HSE with crisis intervention in other countries, and those with lived experience of engaging with gardaí at times of a mental health crisis. The model aims to support the person suffering from an acute crisis and provide them with the care they need, instead of confining them to a police cell.
Cast is a partnership between An Garda Síochána and mental health services at HSE Mid-West, and has been running as a pilot project in the Limerick Garda division. The pilot, which is supported by the Department of Justice and the Department of Health, aims to provide a rapid, compassionate and effective support to people in crisis, reducing the need for arrests or emergency department visits, and ensuring people in distress receive the care and support they need promptly.
The Cast team is based at Henry Street Garda station in Limerick and headed up by Supt Andrew Lacey, whose sense of social justice stems from the influence of his aunt, Sr Eileen Fahey, who in 1983 founded Aiséirí, a holistic addiction treatment service for people suffering from drug, alcohol and gambling addiction.
Cast project comprises two modes of delivery to people in crisis: crisis response and community support.
The crisis response is a joint service provided by An Garda Síochána and mental health services in the HSE Mid-West to respond to relevant 999 calls that have been triaged. The on-scene crisis response involves specially trained members of An Garda Síochána working with their existing operational unit, supported by an assigned clinical nurse specialist and other members of Cast.
The core Cast multidisciplinary team is based at Henry Street Garda station. It includes a sergeant and two gardaí who have received mental health co-response training, a clinical nurse specialist in mental health, a senior social work practitioner and a social care worker.
Lacey says 50 of the 600 gardaí in Limerick have volunteered to receive 45 hours each of specialist crisis mental health co-response training. Cast also has two response cars, with their own unique markings, operated by Garda members working on the project.
Cast team members and co-response gardaí are available during core hours and at night, so there is a good spread of roster coverage, says Lacey.
The team responds to a range of mental health crises, including acute suicidal thoughts or self-harm, severe anxiety, panic or emotional dysregulation, intoxication combined with mental health vulnerabilities, homelessness with coexisting mental health or addiction needs, domestic or relational crises where mental health is central, and individuals in distress who are new to mental health services or disengaged from care.
When an emergency call is triaged to Cast in Limerick, . a car with two gardaí and a clinical nurse specialist in mental health responds. Once they arrive on the scene, the person in crisis i meets a specialist who can assess their needs in a compassionate way.
One of the aims of the project is to prevent unnecessary detentions. While gardaí are responsible for deciding whether a person needs to be taken in under section 12 of the Mental Health Act, for the first time this decision is being made by gardaí with specialist training and the input of clinical experience from the clinical nurse specialist.
Members of Cast also do callbacks for cases where there has been a suicide attempt or acute crisis. Lacey says that although this happens in Ireland in cases of domestic violence, it has never happened before with emergency mental health calls.
Lacey says the callback service is “really valuable” as it allows the team to go back to the person once the immediate crisis has passed and link them with the services they need, such as addiction services or mental health support. “That’s where the real work happens ... that service linkage, that connectivity to finding a solution, positive action plans, linking in with family if it’s appropriate, and they’re seeing the person in that nonchaotic environment.
“What we’re seeing is very few repeat presentations, which is our goal, because if we didn’t do the callback, that person ... may be left here with a letter and never bother going to [an emergency department], which happens quite a bit, that person is not captured [and] is not being picked up. So now, with a new layer coming in to the system, we’re hopefully changing the trajectory of that person’s life.
Coupled with a reduction in repeat presentations or 999 crisis calls, the early intervention by Cast has also led to an earlier diagnosis for some people.
Being arrested under section 12 of the Mental Health Act can be hugely distressing for everyone involved. However, with Cast, the early experiences on the project are that the decision is taken not to arrest the person but to link in with them the next day instead. Once the situation is calmly assessed by highly trained and compassionate professionals, and the immediate crisis has passed, the person can be left in the care of family members in their own home. The person is then contacted by the Cast team the next day, and supports are put in place.
At the heart of the Cast pilot project is its multi-agency support forum. This forum comprises about 15 agencies, including representatives from housing and mental health services, Limerick City and County Council, the emergency department at University College Hospital in Limerick, probation services and community safety wardens. The forum aims to provide an integrated approach to working with people in crisis.
Lacey says some people are frequent users of the emergency services due to their particularly complex mental health and social care needs. The forum identifies those most at risk and meets these vulnerable individuals. According to Lacey, the take-up by people willing to engage with the forum has been “pretty high”.
Once a person has been accepted on to the forum and agrees to engage, they are given support over a number of months. Some may have up to 70 interactions or meetings with the forum.
The Cast community forum has worked with a number of vulnerable patients who were heavy users of emergency services, and preliminary results show that, with the right supports in place, the number of emergency calls by such people to both gardaí and the emergency department has reduced significantly.
While Lacey acknowledges a number of barriers to a national roll-out of the model – such as workforce availability, governance, funding and information-sharing limitations across agencies – he says it should be rolled out to more regions across the country. He suggests that areas of similar size to Limerick – such as Galway, Waterford or Drogheda – may be a good place to start.
“I think we all agree that coming into a Garda station in Henry Street isn’t appropriate, but that’s the way the legislation stands. But there’s now time to do it in a different way, and that is what Cast is,” Lacey says.
The outcomes and impact of the Cast pilot project are being reviewed by experts at University of Limerick and the outcome is due to be published shortly.
- Aware, 1800-804848.
- Pieta House, 1800-247247.
- Samaritans, 116123, or text HELP to 51444
