Little is known about whether the recommendations made during telepsychiatry are actually implemented. We reviewed 100 telepsychiatry consultations, chosen randomly from a paediatric telepsychiatry programme serving rural communities in Ontario. Treatment recommendations had been made for each case reviewed and up to nine recommendations had been made for a single case. Twenty-seven percent of recommendations revolved around monitoring (10%), changing (9%), starting (4%), continuing (3%) and stopping (1%) medication. Case managers associated with 54 of the cases were interviewed to determine whether the recommendations had been implemented and to examine the barriers and facilitators to implementation. The results indicated that cooperation of both child and parent, clear communication of recommendations, involvement of the school and local health providers, stability of the agencies and availability of services were key components in the successful implementation of recommendations. The matter of technology or technological difficulties acting as a barrier to telepsychiatric consultations was not mentioned by case managers, suggesting that it was not a problem.