The SA Health network responsible for Adelaide’s northern suburbs – the Northern Adelaide Local Health Network – was found to have conducted maladministration, as were five managers and clinicians within the network.

The CEO of the Northern Adelaide Local Health Network CEO at the time concerns about Oakden came to light, Jackie Hanson, has been cleared of maladministration, as have each of the ministers and chief executives in SA Health who were deemed responsible, but not culpable, for the conditions at the aged care mental health facility.

Leesa Vlahos did “very little” about Oakden

Then-Minister for Mental Health Leesa Vlahos did “very little” when she read concerns raised about Oakden in the Principal Community Visitor’s annual report in late September 2016, Independent Commissioner Against Corruption, Bruce Lander, writes.

She also did “very little” before her meeting with Jackie Hanson, at which she was informed there would be an investigation by Chief Psychiatrist Aaron Groves into Oakden.

And Vlahos did “very little thereafter”.

“I think she did very little after receiving the Principal Community Visitor’s report on 30 September 2016 and before (her meeting with Hanson on) 19 December 2016 and very little thereafter,” the report reads.

Vlahos a “very poor witness” – refused to take responsibility

Lander described Vlahos as a “very poor witness” who took every opportunity to evade questioning, whose evidence was often internally inconsistent – and who became aggressive, at times, shouting at the Commissioner.

“She was a very poor witness,” the report reads.

“She was sometimes belligerent and aggressive (and) there were times whilst giving evidence when she became angry and on occasions she shouted at me.

“She was evasive in many of her answers and she frequently did not address the questions asked of her.

“Much of her evidence was inherently inconsistent.”

Vlahos also “blamed others for mistakes or failings whenever and wherever possible”.

“She continually sought to exculpate herself from any responsibility for the findings made in the Oakden Report.”

Vlahos failed to read preliminary Oakden report

Vlahos was aware of a preliminary report by Groves concerning Oakden in February 2017, but did not read it, for reasons that Lander found to be “unsatisfactory”.

She argued that she did not read the preliminary report because she wanted to stay at arms-length from the process, and not to be seen to compromise it in any way.

However, Lander writes that it was her responsibility as minister to keep apprised of the situation at Oakden, and that reading the initial report would have done nothing to compromise Groves’ investigation.

“I do not accept Mrs Vlahos’ reasons for failing to read the preliminary report and I do not believe her evidence.”

Jackie Hanson the only one who took “positive action”

Jackie Hanson was CEO of the Northern Adelaide Local Health Network when the Oakden allegations came to light, and resigned earlier this month to take up a post in her home state of Queensland.

Lander found that Hanson was “the only person who took positive action upon becoming aware of the true state of affairs at the Oakden Facility”.

She was also described as a “very impressive witness”, who accepted that she was ultimately responsible for what happened at Oakden.

In contrast to his findings about others in the report, Lander noted that Hanson “did not attempt to deflect responsibility”.

“I have found however that the evidence does not establish that Ms Hanson or her predecessor were aware of the matters that were subsequently found in the Oakden Report.”

Hanson’s “approach merely served to highlight one of the issues with the evidence of Mrs Vlahos, namely that she sought to blame others for what occurred at Oakden rather than materially accepting responsibility”.

Vlahos did not deserve credit for Oakden inquiry

Vlahos has claimed credit for commissioning the Chief Psychiatrist to launch his inquiry into Oakden.

But Lander found that it was Hanson who commissioned the inquiry and rather than “lead” the response to the crisis, “she followed”.

Hanson “saved” Vlahos from a maladministration finding

Vlahos’ “inactivity” in relation to Oakden might have been grounds for a maladministration finding against her, Lander writes.

However, ironically, it might have been Hanson’s actions that saved Vlahos from culpability.

Barbara Spriggs’ complaint about the treatment of her husband Bob at the facility prompted Hanson to commission Groves’ inquiry.

“I think if Ms Hanson had not done what she did following the meeting with Mrs Spriggs on 15 December 2016, it would have been likely that conditions at the Oakden Facility would have continued for a further and unknown period of time,” Lander’s report reads.

“This would have meant that a finding of maladministration might have been able to be made against Mrs Vlahos due to her inactivity.

“However I think Mrs Vlahos has been saved from a finding of maladministration by Ms Hanson’s actions.

“Ms Hanson put in place the review and made the radical staffing changes at the Oakden Facility.”

Snelling told of “neglect” in 2014, but not guilty of maladministration

Then-Health Minister Jack Snelling met with a consultant psychiatrist, Dr Duncan McKellar, who sometimes worked at Oakden, in 2014.

At that meeting, which was also attended by Vlahos, he was told that someone from his office should visit Oakden because it had been “neglected (and) that there were vulnerable people at the facility”.

However, the evidence did not show that “serious issues about the quality of care” were brought up at the meeting.

“The evidence does not go far enough to find that Mr Snelling was aware of the sub-optimal care that was being delivered at the Oakden Facility at any time whilst he was Minister and the evidence does not support a finding that he should have been aware,” Lander’s report says.

“For that reason I cannot make a finding of maladministration in relation to him.”

Ministers and CEOs were responsible for Oakden, but not culpable

Lander finds that while consecutive Health and Mental Health Ministers – Vlahos and Snelling included – were responsible for the conditions at Oakden, as were chief executive officers in SA Health, they were also – to an “astonishing” degree – unaware of what was going on there.

Ministers and CEOs were therefore not guilty of maladministration.

“The evidence I have received makes it quite clear that, to a large extent, what was occurring at the Oakden Facility was unknown to ministers and chief executives,” Lander writes.

“To me that is astonishing. They ought to have known.

“The extent to which senior persons in positions of authority outside of the Oakden Facility did not know about what was occurring at the facility was breathtaking.”

Despite their ignorance, Lander argues, each Minister who had responsibility for the Oakden Facility was “responsible for its failures”.

“So too is each Chief Executive Officer who presided over the agency responsible for the facility.

“So too is each executive or manager who knew of the woeful state of affairs and failed to take appropriate action to ensure that persons in authority, who were in a position and who had the power, ability and willingness to effect change, were informed.”

The managers of Oakden all blamed each other

The three direct managers of Oakden, each blaming the other two, took no responsibility for what happened at Oakden.

The Oakden Facility was managed Dr Russell Draper, Julie Harrison and Kerim Skelton.

They all had other responsibilities outside of Oakden.

Lander writes that all three “sought to avoid responsibility by pointing the finger at the other two”.

They also fostered a “culture of secrecy” and “sought to keep matters ‘in-house’”.

Arthur Moutakis, whose main role was was to manage complaints and reports about facilities within the Northern Adelaide Local Health Network, “played a part in fostering that culture,” Lander finds.

“Rather than properly addressing the complaints, he (Moutakis) appears to have adopted a course of simply accepting what he was told by staff at the Oakden Facility.

“When he became aware of the sub-optimal nursing care being provided at the Oakden Facility, he reported that to (Oakden Nursing Director Kerim) Skelton.

“However, when he became aware that there had been no improvement, he did nothing. He ought to have.”

Chief Psychiatrist could have acted sooner, but not guilty

Lander’s report says Groves could have investigated the Oakden facility earlier once he became aware of the Barbara Spriggs’ complaint about the treatment there of her husband Bob Spriggs.

“He could have taken steps to investigate Mrs Spriggs’ complaint earlier in 2016,” the report says.

“I have also found that he ought to have exercised his powers to make unannounced visits to the Oakden Facility before Mrs Spriggs made a complaint.

“Notwithstanding those findings, I am not satisfied that the evidence is sufficient for a finding of maladministration in respect of Dr Groves.”

Lander’s recommendations

Landers makes 13 recommendations in his 456-page report, including:

• That SA Health review its management of mental health services across Adelaide and review staffing at all mental health facilities.
• That all mental health staff receive new training on reporting dangerous incidents.
• That parliament consider imposing responsibilities on SA’s Chief Psychiatrist to make sure standards of care are upheld.
• The Chief Psychiatrist and the Principal Community Visitor more regularly conduct unannounced inspections of mental health facilities.

You can read Landers full report here.