Report slams a culture of secrecy where process was ignored.
The treatment of residents at the Oakden Older Persons Mental Health Service was a “shameful chapter” in South Australia’s history, according to the state’s Independent Commissioner Against Corruption Bruce Lander
Mr Lander released his official report into Oakden on Wednesday.
“It should not have happened. It must never happen again,” he said.
The 456-page report, Oakden: A Shameful Chapter in South Australia’s History, makes damning findings of maladministration against five individuals and the public authority and contains 13 key recommendations.
The mental health facility was shut down last year after the family of the late Bob Spriggs went public to complain that he had been given 10 times the amount of his prescribed medication and had unexplained bruises before his death.
Other complaints, detailing rough handling of patients, excessive use of restraints and injuries, surfaced.
Mr Lander, who visited the closed facility, described it as “a disgrace” that was unfit for anyone, let alone the frail and vulnerable. It was a place where process and procedures were forgotten or ignored and where systemic failures were allowed to continue for more than a decade, he said.
“Every South Australian should be outraged at the way in which these consumers were treated. It represents a shameful chapter in this state’s history.”
The report levels fierce criticism against SA Government ministers, but stopped short of making maladministration findings against them.
Mr Lander said: “I have made findings of maladministration against five individuals and the public authority responsible for the facility. Those findings do not however tell the entire story of responsibility for what went wrong.
“Senior people, including ministers and chief executives, who were responsible by virtue of their office for the delivery of care and services to the consumers at the Oakden facility, should have known what was going on but did not. I found this astonishing.”
Mr Lander said the evidence he received had revealed a regime where serious complaints about care were not appropriately addressed, where there was a culture of secrecy and where opportunities for intervention were missed.
He warned that because Oakden had been closed before it could be fully investigated, similar failures could occur at other facilities.
The recommendations included:
- The Department of Health and Ageing (DHA) review the clinical governance and management of mental health services.
- All staff at facilities in a local hospital network (LHN) undergo ongoing training as directed by the DHA.
- More frequent unannounced visits to facilities to evaluate patient care, staff capabilities and the physical state of the buildings.
- A review determine the duties and responsibilities of Consumer Advisors and whether further training is required.
- A review of the level and nature of allied health staff support at facilities with mental health services.
SA Premier Jay Weatherill said the Government accepted responsibility for the failings and was working to fix the aged care sector.
“To anybody who suffered abuse at the hands of workers at Oakden, I am deeply sorry," he said on Wednesday.
"To their family members, to their carers, to their loved ones, I am deeply sorry.
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