However, as with his 2015 ICAC probe into the Government’s Gillman land deal, Lander stopped short of making a finding of maladministration against the minister who oversaw the fiasco, Leesa Vlahos, who quit the cabinet last year before leaving parliament altogether two weeks ago.
Instead, findings of maladministration were made against five administrators and clinicians, including the “triumvirate” who shared management responsibility for the disgraced – and now-closed – facility, Julie Harrison, Kerim Skelton and Russell Draper.
Lander also found that the public authority responsible for the facility – the Northern Adelaide Local Health Network – itself “engaged in maladministration in public administration”, despite declaring its chief executive, Jackie Hanson, was “in the end the only person who took positive action upon becoming aware of the true state of affairs at the Oakden Facility”.
Lander’s report is subtitled “A Shameful Chapter in South Australia’s History”, and its contents underline that description.
“Every South Australian should feel outraged at what happened at the Oakden facility,” Lander writes in an attached statement.
“The consumers at Oakden were poorly cared for, forgotten and ignored… the facility itself was grossly substandard.”
He makes 13 recommendations for change, including a review of the clinical governance and management of the state’s mental health services.
Premier Jay Weatherill today repeated his apologies over his Government’s handling of the facility, saying: “There’s no relief here – it’s just all shame [and] an extraordinary sorrow for a disgraceful way in which older people were being treated, and anger about the fact people did it and then covered it up.”
“As the leader of the Government I have to accept responsibility for the failings at Oakden,” he said.
“The way we’re accepting responsibility is to act to fix it.”
Despite not making maladministration findings against ministers, he emphasised “those findings do not however tell the entire story of responsibility for what went wrong at Oakden”.
“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,” he said.
“I found this astonishing.
“One might ask rhetorically how, in a modern society, an arm of government charged with caring for some of our most vulnerable citizens could provide such abysmal care over such an extended period of time without intervention.”
He says while the goings-on at Oakden were unknown to ministers and chief executives, he adds: “To me that is astonishing.”
“They ought to have known.
“Nevertheless, each Minister who had responsibility for the Oakden Facility is responsible for its failures. So too is each Chief Executive Officer who presided over the agency responsible for the facility.”
Lander said his investigation had “reinforced my view that the ICAC Act should be amended to give me the discretion to conduct such investigations in public” – a plea that has thus far fallen on deaf ears within the Labor Government.
He also revealed that it was Vlahos and two public servants – Harrison and the centre’s Clinical Services Coordinator Karim Goel – who sought to have their names redacted from the final report – an objection Lander claims “inevitably led to a delay in the finalisation of the report”, seeing it handed down little more than two weeks from polling day.
She did not lead in addressing the crisis. She followed
Ironically, when Vlahos fell on her sword this month, she stated she expected “no adverse finding” but did not want her candidacy to “become a distraction”.
But Lander makes it clear Vlahos only narrowly avoided a finding of maladministration, declaring that if not for an independent inquiry by former chief psychiatrist Aaron Groves – instigated by Hanson – “it would have been likely that conditions at the Oakden Facility would have continued for a further and unknown period of time”.
“This would have meant that a finding of maladministration might have been able to be made against Mrs Vlahos due to her inactivity,” Lander writes.
“I think Mrs Vlahos has been saved from a finding of maladministration by Ms Hanson’s actions.”
Vlahos subsequently took credit for instigating the review, which also drew ire from the commissioner.
“Mrs Vlahos’s assertion that she was the one who commissioned the report is not supported by the evidence,” he said.
“In my opinion her assertions were over-reach. She did not lead in addressing the crisis. She followed.
“All but one Minister who had responsibility for the Oakden Facility over the past decade accepted some measure of responsibility for what occurred. Mrs Vlahos sought to deflect responsibility.”
She was sometimes belligerent and aggressive… at other times sullen and surly
He is scathing of her attitude to his inquiry, describing the former minister as a “very poor witness”, who refused to take responsibility for what happened at Oakden and took every opportunity to evade questions.
“The statement that she provided… was curt and aggressive and generally unhelpful. It omitted a significant amount of information,” he writes.
Under questioning, “she was sometimes belligerent and aggressive… at other times sullen and surly”.
“There were times whilst giving evidence when she became angry and on occasions she shouted at me,” Lander says.
“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.
“She 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 has come under fire for failing to read Groves’ preliminary report, with Lander declaring he does “not accept” her reasons for not doing so “and I do not believe her evidence”.
He says former Health Ministers John Hill and Jack Snelling, by contrast, “both accepted some measure of responsibility for the conditions at the Oakden Facility during their time as Ministers”.
At one point under questioning, Vlahos attributes the culture at Oakden to a lack of oversight by the local health network, saying: “If I had my way at the beginning of February , I would have sacked the lot of them, but I couldn’t because of industrial relations.”
“I may well have sacked some good people along the way, but as the time came out, we’ve tried to establish who has got good true hearts,” she said.
Lander is also scathing that Vlahos delayed by a month the tabling of a damning report by the Principal Community Visitor in 2016 until the last parliamentary sitting day of the year. The then-minister gave “a number of inconsistent explanations for her failure to comply with her statutory obligation”, including that her office was on a “‘fact finding period’ during which ‘we were establishing the scope of what was happening at Oakden’ and that ‘we wanted answers’”.
“In view of the way in which she gave her evidence, it is open to me to find that her evidence was deliberately untruthful,” Lander finds.
While Lander did not make official findings against ministers, he raises the prospect that problems at the centre might have been brought to cabinet attention as far back as 2014, even though neither Snelling nor Vlahos visited the facility until February last year.
“Snelling said that when he was first briefed about the Oakden Facility he was informed that the Department was keen to get out of the Facility as it was not core business,” Lander states.
Snelling said that he did not want to take on the unions three months before an election and this was likely the reason why nothing was done
“He understood that while privatisation was a government priority, it was not a priority for him and that his main concern was industrial disruption and that he did not want to have an ‘industrial war’ as he understood the unions would oppose privatisation.”
Snelling conceded there was “no political will to change the model so as to avoid an argument with the unions”, he notes.
“The unions were strongly opposed to the proposal (particularly the Australian Nursing and Midwifery Foundation) as the proposal would have resulted in loss of public service jobs… Mr Snelling said that he did not want to take on the unions three months before an election (in March 2014) and this was likely the reason why nothing was done towards the end of 2013.”
Lander notes he did not consider whether cabinet itself engaged in maladministration “because the Cabinet is not a public officer or a public authority and is therefore not amenable to my jurisdiction”.
Weatherill, who initially praised Vlahos for “shining a light” on Oakden, said today he would meet with family members to discuss the report and the Government’s response.
“As the leader of the Government, I have to accept responsibility for the failings at Oakden,” he told reporters.
“Leesa Vlahos told me that she led the process – Commissioner Lander found that she didn’t, and I accept his findings.
“She anticipated obviously some criticism from this report and has made the decision to resign from the ministry… so obviously she had a sense that there may be some criticism and of course there has been.”
Weatherill described her behaviour at ICAC as “unacceptable” but declared “she’s not a candidate of the Labor Party”.
The Premier said he was “deeply sorry” to the people who had suffered abuse, as well as their families and carers.
They all “deserved better” both from the workers at Oakden and those who were meant to be supervising them.
Alma Krecu, whose father Ermanno Serpo suffered horrific abuse at the centre before his death, including physical violence, over-medication and neglect, told InDaily she was still grappling with the lengthy report and was “a bit shell-shocked”.
“I’m concerned about how long they really knew there was an issue and it was not reported through the right avenues… my concern is really how long have the Government been aware of this?” she said.
Krecu said while the report had “answered some questions, I think it’s left other questions unanswered – again”, and that she was disappointed key ministers had been “spared”.
“If we can’t trust them in the positions they’ve got to do the right thing, what hope have we got?” she said.
She said Vlahos had “clearly accepted no responsibility” and that “Jay Weatherill should have sacked her back last year when this came out”.
“Instead he let her fall on her sword four weeks before an election, and said it was the ‘right choice’… it should have been the right choice for him to sack her when the Oakden report came out, to be quite honest,” she said.
SA Best leader Nick Xenophon said the report was “harrowing and truly shocking reading” which “shows there needs to be reform”.
“This raises fundamental issues of ministerial accountability – ministerial responsibility is broken in this state and there needs to be fundamental reform,” he said.
“There must be new standard… if the minister ought to have known about it, the minister should no longer be a minister.”
Xenophon also said the scandal “highlights the need for a stronger parliament and a stronger and more open ICAC”, including giving the body powers “to view cabinet documents for investigative purposes” – a request that was refused by Weatherill’s administration.
The timing and damning contents of the report could turn the election campaign on its head, with Liberal leader Steven Marshall declaring: “Labor has failed our most vulnerable citizens in SA and they deserve to be sacked on March 17.”
“If anybody needs any proof whatsoever that this is the worst government in the state’s history they can read about it today,” he told reporters.
“Bruce Lander says that the people of SA should be outraged – I’m outraged.
“Jay Weatherill has been out there running a protection racket for his incompetent ministers over an extended period of time. He was out there saying that Leesa Vlahos was doing a great job shining a light on the dysfunction at Oakden – well that is completely in contrast with the evidence.
“Now we know why the Government opposed open ICAC hearings.”
Of the five public servants deemed to have committed maladministration, Lander says Oakden managers Draper, Harrison and Skelton “each sought to avoid responsibility by pointing the finger at the other two”.
“It was an extraordinary management structure… nobody had overall control over the facility. Nobody had fulltime responsibility solely for Oakden,” he wrote, saying that the trio “fostered a culture of secrecy within the facility [and] sought to keep matters ‘in-house’”.
A fourth bureaucrat, Arthur Moutakis, “whose primary function was to manage complaints and reports about facilities within NALHN played a part in fostering that culture”.
Moutakis, the ICAC found, “failed to appreciate the significance of the complaints he was receiving about the Oakden Facility [and] appears to have adopted a course of simply accepting what he was told by staff”.
The fifth, Merrilyn Penery, was most recently the Clinical Practice Consultant at Oakden. Lander said Penery “knew that serious concerns about nursing care were not being properly addressed”.
“She had an opportunity to raise those matters with persons more senior within NALHN. She did not do so. She ought to have,” he said.
Weatherill said four of the five were no longer employed by the government, and the fifth was currently on leave.
Lander said there were “salient lessons to be learned for many agencies”.
“The consumers who resided at the Oakden Older Persons Mental Health Service were some of the most frail and vulnerable persons in our community. They did not have a voice. They were obliged to live in a facility which could only be described as a disgrace, and in which they received very poor care. The process and procedures were such that they were forgotten and ignored. The State did not provide them with the level of care that they deserved.
“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.
“It should not have happened.
“It must never happen again.”
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