Oakden: A Shameful Chapter in South Australia's History

Summary

The report's own summary: EXECUTIVE SUMMARY, pages 16 to 23

Findings, opinions and statements 10

Allegations are not findings. A commission's finding or opinion of corrupt conduct or misconduct is not a finding that a person is guilty of a criminal offence, and the commissions say so in their reports.

1. maladministration

   Finding

   I have found that NALHN engaged in maladministration in public administration.

   Report, page 21

2. maladministration

   No finding

   The evidence does not permit a finding that any Minister engaged in maladministration within the meaning of s 5(4)(a)(i) of the ICAC Act.

   Report, page 244

3. maladministration

   No finding

   However, for the reasons I have mentioned I do not find that Ms Gago engaged in conduct that amounted to maladministration.

   Report, page 246

4. maladministration

   No finding

   I therefore do not find that Mrs Vlahos engaged in maladministration in public administration.

   Report, page 253

5. maladministration

   No finding

   While the evidence does not permit a finding of maladministration against any of the Ministers, it remains the fact that they were, as Ministers, responsible for the Oakden Facility and for the care provided there during the time that they were Ministers.

   Report, page 255

6. maladministration

   No finding

   In my view the evidence does not support a finding of maladministration against the former CEOs of NALHN.

   Report, page 265

7. maladministration

   No finding

   Therefore, I am not satisfied they engaged in maladministration in public administration.

   Report, page 275

8. maladministration

   No finding

   In light of the fact that I have formed the view that the evidence does not support a finding of maladministration against Mr Goel or Mr Torzyn, it is not necessary for me to set out what their official functions were.

   Report, page 275

9. maladministration

   Finding

   Accordingly, I find that Dr Draper, Ms Harrison and Mr Skelton all engaged in maladministration in public administration, for the reasons identified in this report.

   Report, page 297

10. mismanagement

    Finding

    I find that the practices, policies and procedures of NALHN gave rise to a substantial mismanagement of public resources in that the mechanisms that were available for reporting complaints, issues, incidents or concerns were either inadequate or inadequately supervised such that they failed so that matters of concern that ought to have come to the attention of persons at various levels did not do so and, consequently, they were never addressed.

    Report, page 305

Recommendations 13

1. Recommendation 1

   The Chief Executive of the Department of Health and Ageing (Chief Executive) review the clinical governance and management of mental health services within the overall clinical governance of each Local Health Network (LHN) to determine whether the management requirements of the Mental Health Act 2009 (MHA) fit within the overall health governance structures.

   Report, page 21

2. Recommendation 2

   The Chief Executive should, with the Chief Psychiatrist and the Chief Executive Officers (CEOs) of the LHNs, consider adopting management structures for the administration of the MHA to match those of overall mental health clinical governance structures, such that: • the officer responsible for the clinical mental health care of a facility within a LHN is also responsible for the administration of the MHA at that facility; and • the officer responsible for overseeing all clinical mental health care within a LHN has the responsibility for the administration of the MHA in that LHN.

   Report, page 21

3. Recommendation 3

   The Chief Executive and the CEOs implement a structure to routinely remind all staff working at a treatment centre of the management structure in place at the centre; the assignment of responsibilities at the centre; and the expectations and responsibilities imposed upon each member of staff at the centre.

   Report, page 21

4. Recommendation 4

   The Chief Executive direct all staff at facilities in a LHN where mental health services are being delivered to undergo training, as may be agreed by the Chief Executive, Chief Psychiatrist and CEOs, in the use of the Safety Learning System; the reporting obligations for staff under Commonwealth and State legislation and the relevant SA Health and LHN policies and procedures.

   Report, page 21

5. Recommendation 5

   The Chief Psychiatrist review the use of the statutory power conferred on the Chief Psychiatrist under s 90(4) of the MHA to conduct inspections of an incorporated hospital, with a view to the Chief Psychiatrist exercising the power to conduct unannounced visits to facilities within LHNs more frequently than in the past.

   Report, page 22

6. Recommendation 6

   The Principal Community Visitor review the use of the statutory power conferred on community visitors under ss 51(3) and 52 of the MHA to conduct unannounced inspections and visits of facilities within LHNs and treatment centres, with a view to community visitors exercising the power to conduct unannounced inspections and visits more frequently than in the past.

   Report, page 22

7. Recommendation 7

   The Minister for Mental Health and Substance Abuse (the Minister) cause a review to be conducted of the community visitor scheme (CVS) to determine whether the CVS should be amended to: • require community visitors be trained in mental health care; • require community visitors to possess certain qualifications in mental health care; and • provide that some of the community visitors’ current functions be discharged by persons with specialist qualifications in mental health.

   Report, page 22

8. Recommendation 8

   The Minister cause a review to be conducted to determine whether the MHA should be amended to impose positive obligations on the Chief Psychiatrist to ensure: • that public officers within the LHNs delivering mental health services comply with their obligations under the MHA; and • as far as practicable that an adequate standard of care is provided to persons with a mental illness who receive such care from a LHN; and whether in that case the resources of the Office of the Chief Psychiatrist need to be increased; and • if so to what extent; and • whether the Chief Psychiatrist should be provided with further statutory powers to enable the Chief Psychiatrist to perform any such additional functions.

   Report, page 22

9. Recommendation 9

   The Minister cause a review to be conducted for the purpose of reporting publicly on the physical condition of all facilities at which mental health services are delivered in a LHN: • for the purpose of determining whether the physical condition of those facilities are fit for the purpose for which they are being used; and • if not in what respects the physical condition of any facility is not fit for purpose.

   Report, page 22

10. Recommendation 10

    The six recommendations contained in the Oakden Report be implemented, to the extent that they have not already been implemented.

    Report, page 22

11. Recommendation 11

    The Chief Executive review the role of Consumer Advisor to determine whether: • the duties and responsibilities of Consumer Advisors, so far as they relate to facilities at which mental health services are provided, are appropriate; • Consumer Advisors require further training to assess the significance of complaints made about those facilities or services; • Consumer Advisors should be required to report complaints in respect of facilities to particular persons or committees; and • steps can be taken to ensure Consumer Advisors are independent of particular facilities.

    Report, page 23

12. Recommendation 12

    The Chief Psychiatrist and the Chief Executive review the use of restrictive practices within each LHN with a view to the Chief Psychiatrist exercising power under s 90 of the MHA to issue new standards in relation to the use of restrictive practices and making the observance of those standards mandatory.

    Report, page 23

13. Recommendation 13

    The Chief Executive, in conjunction with the CEOs, review the level and nature of allied health staff support at facilities at which mental health services are provided by a LHN for the purpose of determining whether there are adequate allied health staff to provide the necessary support at such facilities.

    Report, page 23

Published responses 1

• The Commissioner’s report was released on 28 February 2018, prior to the March 2018 State election. The State Government at the time responded to the report , accepting all 13 recommendations and indicating how it proposed to implement them.

  Agency response

  Report, Report page

Coverage

This publisher

• Office for Public Integrity: publishes only its annual reports (excluded); no OPI report or statement records.
• Since October 2021 the Commission does not make findings of corrupt conduct; most records have no findings.
• Government and agency responses are recorded only where the Commission's page links them or the report reproduces them; implementation status is not published by the Commission as structured data.
• Scanned reports without a text layer are not read (no OCR); their recommendations stay not_extracted.
• Recommendations are extracted only from numbered 'Recommendation N' lists; reports that set out recommendations in prose, tables or unnumbered lists keep recommendations_status not_extracted.
• Findings are extracted only from investigation reports that state them in the Commissioner's own words (Oakden 2018, Gillman 2015); public statements are not read for findings.