Adult with intellectual disability was found to have bitten into a toxic item on two separate occasions
Health regulators issued an urgent call for a disability care centre to implement risk control measures, after they were told that one of its residents had been involved in two ‘serious adverse incidents’ due to inadequate living conditions.
St Michael’s House in Ballygall, Dublin 11, was found non-compliant in seven areas, including protection, residents’ rights, and governance and management after an inspection from the Health Information and Quality Authority in October. Three adults with intellectual disabilities were living in the facility at the time of the inspection.
In one incident which occurred last January, an unsupervised resident had bitten into a toxic inedible item. The resident was later found with three of these items in their hands, and evidence of the toxic substance on their lips and hands.
In May, a similar second incident took place involving the same resident, with no control measures having been put in place in the interim to prevent its re-occurrence.
“Staff members communicated to the inspectors that they had endeavoured to raise concerns regarding risk management to the provider, however, their concerns were not adequately responded to,” noted the inspectors in their report.
“On both incidents, where a resident had potentially ingested toxic items, the staff team contacted the nurse manager on-call for guidance.
“The inspectors saw that there was a risk assessment for battery/chemical storage, however this provided general control measures which were not specific to the risk identified.
“Staff members spoken with stated they were not aware of any risk assessments for this particular risk, and that there was an absence of protocols to guide them in managing the risk.”
The revelation led the inspector to issue an urgent action to the disability centre to submit a comprehensive risk assessment of the issue that would include control measures to prevent the incident reoccurring.
“The provider’s urgent compliance plan response provided assurances that the urgent risk had been mitigated,” wrote the inspectors.
Incident report forms kept by the centre also found that a keypad prevented staff from quickly exiting a resident’s living space. In one incident in 2025, a staff member was assaulted as they could not exit quickly enough due to the delay it took to access the keypad.
A glass panel in a sitting-room door also posed a risk to residents. Earlier in the year a resident had broken a panel ‘as a result of self-injurious behaviour’.
While inspectors were told that the resident had not been injured, staff described receiving a lack of support from their employer in responding appropriately to the incident and ensuring the resident’s safety, as they continued to attempt to access the panel which contained broken glass.
“The panel was replaced by a Perspex panel; however inspectors were told that this was due to be changed back to a glass panel,” noted the report.
“Staff members expressed concern regarding the potential for a similar incident to re-occur and also for the ongoing potential for further injury to the resident, who regularly engaged in self-injurious behaviours on the window.”
St Michael’s House Ballygall was one of 21 inspections published by HIQA yesterday. Non-compliances were found in six of these centres, including a facility operated by Stewarts Care DAC, where inspectors said that inappropriate living arrangements impacted upon the welfare of residents. The premises of a centre operated by Kerry Parents and Friends Association was found to have not met the needs of residents.
Poor governance was also identified at three centres operated by Avista CLG. In one centre, a review of restrictive practices and residents’ risks was required, with improvements also required in staffing and staff training. In the remaining two centres, improvements were required by the provider in risk management and staff training.
However, inspectors found a generally good level of compliance with the regulations and standards in 15 centres operated by a number of providers including: Ability West; Avista CLG; Brothers of Charity Services Ireland CLG; Dara Residential Services; Dundas Unlimited Company; Embrace Community Services Ltd; Health Service Executive (HSE); Kingsriver Community Holdings CLG; Muiríosa Foundation; St Michael’s House; and Stewarts Care DAC.
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