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How the State Government failed SA's most vulnerable at Oakden

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The State Government has offered apologies, but not accepted responsibility, for the appalling mistreatment of our most vulnerable elderly people at its mental health facility in Oakden over more than a decade. But it most certainly failed those patients and their families. Here's how.

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The Oakden Review, penned by Chief Psychiatrist Dr Aaron Groves and released yesterday afternoon, is a damning indictment not only of staff accused of mistreating and abusing patients at the Oakden Older Person’s Mental Health Service – but of the State Government and SA Health.

The Government relied on “failed accreditation” of the facility by the Commonwealth for its defence.

However, as its own report finds, the Government failed to properly fund the centre and presided over a severe shortage of staff: as late as January, Oakden had up to 44 fewer staff than it needed.

It ignored multiple warning signs about the facility, over more than a decade.

And the committee trusted to oversee Oakden did not understand its own responsibilities.

State Govt relied on national accreditation, which failed repeatedly

Mental Health Minister Leesa Vlahos told ABC Radio Adelaide this morning that the facility had repeatedly met Commonwealth accreditation standards and, where it had not, those concerns were generally addressed.

“Every time there have been concerns raised by the Commonwealth Accreditation Agency, or concerns raised, those issues have generally been addressed … that happened before I was the Minister.

“We’ve met the accreditation standards and as recently as February 2016 we were re-accredited up until 2019.”

But according to the review, the reliance on “failed accreditation” promoted a “sense of comfort” that Oakden was performing well, when it wasn’t.

The review reads: “It is an important lesson for all involved in trying to ensure that the best care is provided that reliance only on periodic reviews, such as accreditation, leads to a sense of comfort that may not be meritorious.”

“The review heard and saw evidence that Oakden became better at knowing how to produce documents and records that accrediting bodies and surveyors wanted to and expected to see; and better at ensuring staff knew what to say [but] no better at providing safe or better quality care.”

From as early as 2005 until the present day, “the review did not find an appreciable difference in the overall level of clinical outcomes over that entire period”.

“Put another way, the problems in 2016 are seen as far back as one looks.”

Oakden was up to 44 staff short

SA Health was unable to demonstrate for the review how many people were actually employed at Oakden.

Despite this uncertainty, the review identified a severe staff shortage.

As late as January this year, according to the review, Oakden was up to 44 staff members short.

According to the review: “On the basis that Oakden when fully occupied currently has 62 commissioned beds … the NMHSPF [national standards] would suggest Oakden requires 100.4 full-time equivalent clinical staff”.

“Therefore the shortfall may be as high as 44 full-time equivalent at the level of funding in January 2017.”

At current occupancy levels, the facility “would be at least 10.5 full-time equivalent [staff] short of what is required for even the currently significantly reduced occupancy within the facility”.

“Over several years, Oakden has had insufficient access to Social Work, Occupational Therapy, Psychology and Clinical Pharmacy services that would be critical for ensuring the service provided a high level of safe care,” the report says.

There was also an apparent shortfall in nurses, and “this apparent shortfall is more profound when taking into account the poor levels of skill and training of many of the Nursing staff”.

The warning signs were there

According to the review, “the first indication that Oakden may have been experiencing quality issues was in 2001”.

Six years later, in December 2007, the facility failed 25 of the Commonwealth’s 44 standards for aged care and was given “sanctions”.

In 2008, Oakden was found to be non-compliant with accepted aged care standards – so the government health body for the region, the Central Northern Adelaide Health Service, commissioned an external review.

While some of the external review’s findings had been addressed by the time Groves and his team undertook the latest review, 13 of its negative findings were still true.

Overall, problems with the facility that were raised in 2007 have remained “present throughout the last 10 years”.

And aside from the formal warnings, other “warning signs such as the rate of injuries, medication errors, excessive mechanical restraint, numerous falls, unexplained bruising, failed accreditation, poor documentation and unidentified clinical deterioration were present but the signs were not heeded”.

Years of looming closure undermined funding, staff

The idea of closing Oakden is not new.

According to the review, the notion that the facility would be closed and handed over to a non-government provider – which the review says would have contravened international standards – began to “permeate through staff” as early as 2001.

It was reinforced by a proposal, within SA Health, of a new “model of care” in 2012.

The model was never implemented, but was relied upon by executives to justify rejecting repeated requests for more funding, and it made attracting staff difficult.

The review states that the reliance of executive level mental health staff on the flawed 2012 model “contributed to the deficits now evident at the Oakden campus because of the disconnection between an unfunded aspirational document and the real-world challenges of the service, when no process to identify the resources needed to implement a new model is made”.

“From 2010, the Review heard that requests for maintenance of the building and replacement of broken, damaged or new equipment from staff were regularly responded to with statements such as: ‘there’s no funding for that’, ‘borrow it from next door’, ‘it’s not going to happen in this financial year’.

“The review team was repeatedly informed by a variety of staff of statements made by Mental Health Executive members during the last five years, stating that investment in resources at Oakden was not made because the service was to be outsourced to a private provider.”

Moreover, “convictions that the service would close … [meant] attracting new staff was increasingly difficult”.

“Anyone who wanted permanent, secure employment did not consider Oakden a viable option and staff reported a sense of inevitability that both their workplace and their employment were limited.”

“The fish rots from the head”

SA Health’s Northern Adelaide Local Health Network [NALHN] is responsible for mental health services in the north.

The review heard that responsibility for clinical outcomes at Oakden now falls on NALHN’s Divisional Director for mental health and the Clinical Lead for the Older Person’s
Mental Health Service.

But the lines of reporting have changed over time, and staff at the facility were unable to identify who was ultimately responsible for ensuring the safety and quality of patient care.

The review was “disturbed to find” that members of the clinical governance committee for the Older Persons’ Mental Health Service did not understand their responsibilities.

And only about half of the committee’s scheduled meetings actually occurred.

Committee members told the review that “most attendees did not know the fundamental principles of clinical governance”, that “there was an absence of leadership”, that “nobody was held accountable, actions were not followed up” and that “apathy pervades the building”.

“This shortfall in commitment at the highest level of senior leadership within the older persons’ mental health service has consequently lead to little or no understanding of Clinical Governance at lower levels within the organisation,” the review reads.

“The results of this failure are captured in the organisational phrase ‘the fish rots from the head’.”

Throughout the review, “there was no consistent view of who was in charge of clinical outcomes in Oakden”.

“The more we asked the more we heard people say it was someone else.”

Only one person, during the review process, admitted that they had done anything wrong.

“One senior staff member said that after reflection ‘I failed. I did not do my job properly’,” the review says.

“We did not hear anyone else, who might have had a role to play, say that they should have done anything different.

“This in itself is telling.”

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