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Patients “cowering in fear”: SA Health was warned about unsafe mental health unit


EXCLUSIVE | Patients recovering from surgery and those with mental illness were forced to share bedrooms at the “appalling” mental health unit SA Health closed late last year, InDaily can reveal.

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Lyell McEwin Hospital mental health scandal

Mental health patients were found “cowering in fear” beside their beds at the Lyell McEwin Hospital mental health short stay unit, where safety and privacy were compromised, and which shared space with a surgical ward, according to reports sent to SA Health in 2016 and 2017.

A summary of Community Visitor Scheme reports from those years, obtained exclusively by InDaily, reveals shocking new details about the inadequacy of the facility and care provided there, which were apparently known to SA Health well before the department closed it in December 2017.

“They knew… that it’s less than adequate,” Principal Community Visitor Maurice Corcoran told InDaily.

“It’s absolutely awful.”

The reports raise questions about exactly what SA Health knew about conditions at the short stay unit and was done about it.

It is believed that some of the same sections of the Northern Adelaide Local Health Network involved in dealing with the short stay unit issues were also subject to questioning about knowledge and actions taken concerning standards of care at the Oakden Older Person’s Mental Health Service, during the Independent Commissioner Against Corruption’s investigation into that disgraced service.

Corcoran said his office’s reports about the short stay unit were being sent to SA Health during the same period that Community Visitor Scheme reports were being sent concerning Oakden.

The Community Visitors Scheme inspects psychiatric facilities, reporting Government on the treatment of mental health patients.

On several occasions in the past two years, short stay unit staff told the CVS visitors the facility was unfit for mental health care and incompatible with the surgical ward that shared the space.

“These adverse impacts included reports of mental health patients cowering in fear / angst beside their beds as visitors and staff would enter and disturb the patient on a regular basis,” a summary of an April 2017 entry reads.

In October 2016, three people receiving mental health treatment “were sharing the bedroom with the surgical unit, which is not ideal”.

Two months later, another mental health patient “needed to share a bedroom and toilet with a surgical patient”.

A spokesperson for SA Health told InDaily this afternoon that the department uses the reports to improve its services.

“When a CVS report is received, every recommendation is formally assessed and quality improvement strategies are considered for implementation,” the spokesperson said in a statement. 

“These implementation strategies are continually reviewed to ensure patients are receiving the best care to meet their mental health needs.

The CVS reports provide important and independent feedback on how we shape our services for the benefit of patients and staff.”

The CVS reports chronicle failures to provide a “minimum” amount of therapeutic activities – a problem that “has been reported for more than a year” – as well as alleged breaches of patient confidentiality.

And despite SA Health claiming this week that the unit was fully staffed at all times, the reports add to a growing body of evidence that suggests otherwise.

The department told InDaily on Wednesday that the short stay unit “maintained an appropriate patient-to-staff ratio that included a social worker, psychologist and nurses at all times”.

A summary of a CVS report from March 6, 2016 reads: “Lack of staff is also an issue which compromised the quality of care due to the conditions of a hectic environment that demands extra supervision of consumers and high turnover of clients … there is not a permanent social worker.”

The SA Health claim also contradicts 10 separate safety notifications from the unit’s staff that, as InDaily revealed this week, reported a lack of available staff, and patients having to stay “clinically unnecessary” days waiting for a referral to a social worker.

The department spokesperson offered no response when asked about the accuracy of SA Health’s claim that the unit was fully staffed at all times.

As InDaily has also exclusively reported this week:

Short stay units were established in Adelaide’s major hospitals as part of the controversial Transforming Health reform program, aimed at stopping mental health patients from remaining in emergency departments for days on end.

They were intended as quieter, more therapeutic spaces where patients could be psychiatrically assessed and treated, away from noisy, crowded EDs that tend to inflame already acute mental health conditions.

But the Lyell McEwin Hospital short stay unit was itself noisy and crowded, CVS reports from October 2016, December 2016, July 2017 and October 2017 warned, and therefore “not conducive to mental health care”.

The “serious incompatibility” of the co-located surgical and mental health units was causing “significantly adverse impacts” and was “not treatment-friendly”, as well as breaches of patient confidentiality.

“Patient confidentiality is not being observed as patient needs and care plans are openly discussed in the presence of patients/client who may be at the nurses’ open administration desk,” a summary of a July 2017 CVS entry notes.

A 2016 entry into SA Health’s adverse events record, the Safety Learning System, records a confidentiality breach involving two patients.

“The other consumer contacted the affected consumer to inform her of what happened, and the guarantee that the information would not be shared with anyone,” it reads.

Corcoran said the CVS reports were sent during the period that his team was sending concerns about Oakden to the same individual.

Independent Commissioner Against Corruption Bruce Lander this year found that NALHN’s management of Oakden constituted maladministration.

“The staff (at the unit) acknowledged that it wasn’t fit for purpose,” said Corcoran.

“It wasn’t a safe ward … and everyone was aware of that.

“NALHN should’ve been aware of that.”

“The unit, he argued, was “a Band-Aid strategy in many regards, to get people out of the ED before they hit the 24-hour target”.

In 2016, InDaily revealed that mental health patients had been made to wait for more than 24 hours in SA emergency departments almost 800 times between January and November 2016 – contrary to the department’s target that “by 1 January 2016, mental health consumers should not routinely wait more than 24 hours in an emergency department”.

The establishment of short stay units in several Adelaide hospitals including the Lyell McEwin coincided in significant drops in wait times for mental health patients in emergency departments.

Corcoran said NALHN had responded to concerns about the short stay unit by holding regular meetings with staff about how the facility may operate more effectively and by installing duress alarms.

But the responses did not address the co-location problem and the unit itself was always meant to be temporary, he said.

The CVS reports say that SA Health had planned a new, purpose-built short stay unit, but the idea was later abandoned.

“There is now an ongoing project approved for new purposefully built short stay unit under the “transforming health project” – hopefully that will create a super specialised mental health support services in Northern area,” a summary of a November 2016 entry says.

In February 2017: “The construction of a new ward has been approved but there is no date for when it will start.”

But by October that year: “Concerning to know that the project to build a SSU unit was cancelled, considering that the ward … where the unit is allocated does not meet the mental health therapeutic environment requirements.”

Doctors’ union SASMOA told InDaily in February this year, after the short stay unit was shut down, that the State Government had failed to find funding to replace it.

A week later, almost exactly a month before the state election, the Weatherill Government announced it had found $5 million to replace it.

According to SA Health, plans for a replacement were progressing.

InDaily contacted Mental Health Minister Stephen Wade for comment.

If you have experience of the Lyell McEwin Hospital mental health short stay unit, we’d like to hear from you.


If this article has raised issues for you, you can call LifeLine on 13 11 14 – or you can call the Mental Health Triage Service / Assessment and Crisis Intervention Service on 13 14 65.

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