New mental health scandal hits SA Health

SA Health made the decision to close the Lyell McEwin Hospital mental health short stay unit in December 2017 after the union’s safety inspector reported a number of “extremely obvious ligature points” – features of a room that can enable suicide.

“Workers believe it is only a matter of time before a preventable death occurs caused by the facilities,” said the report, penned by South Australian Salaried Medical Officers’ Association senior industrial officer Bernadette Mulholland.

This is one of the most appalling and unsafe sites … inspected to date.

“Patient safety is compromised as medical officers are unable to provide the necessary care, with the floor plan of the beds not allowing for a clear line of vision to the patients.”

The unit was administered by the Northern Adelaide Local Health Network – the same organisation that had managed the scandal-ridden Oakden Older Person’s Mental Health Service.

Earlier this year, Independent Commissioner Against Corruption Bruce Lander found NALHN had engaged in maladministration in its handling of that facility, which had become unfit for patient care.

InDaily can reveal that reports from SA Health’s adverse events record, the Safety Learning System, indicate that two patients had used the physical features of the Lyell McEwen mental health unit to attempt suicide in 2016.

A report about a third self-harm incident is more ambiguous, but says staff had to intervene to ensure that patient’s safety.

The reports are among more than 40 incidents of deliberate self-harm recorded in the documents.

InDaily has chosen not to publish the details of the reports but all indicate the patients required intervention to ensure their safety.

In response to questions from InDaily, SA Health said “all Local Health Networks undertake regular ligature audits of their mental health facilities at least once a year”.

“On attendance each patient was assessed and had an individual care and referral plan, in addition to broader approaches such as decreasing rates of seclusion, limiting the use of restrictive practices and increasing frequency of observations.”

The safety reports, released to Greens MLC Tammy Franks under freedom of information laws and obtained exclusively by InDaily, also show regular complaints about unsafe levels of staffing at the short stay unit.

Five entries in 2016 and a further five in 2017 record a lack of appropriate staff posted to the facility.

“Occupational health concerns – huge burnout for staff … unable to monitor patients properly due to large amount of admission in short time,” one of the 2016 entries says.

“Increased work load can potentially lead to staff fatigue and increase in missed care,” says another.

Another 2016 entry records staff struggling to de-escalate a situation in which two patients each required one-on-one care, and that “surgical staff is busy and unable to assist”.

Most of the 2017 entries related to inadequate staffing reported a lack of available social workers in community mental health, meaning patients had to remain in the facility longer.

One of the entries records a patient remaining “three clinically unnecessary days in hospital to see social worker”.

In a statement to InDaily, SA Health insisted that “the unit maintained an appropriate patient-to-staff ratio that included a social worker, psychologist and nurses at all times”.

Yesterday, InDaily revealed that three people had taken their own lives after leaving the short stay unit – one in 2016, another in 2017 and another in an undisclosed year.

And Safety Learning System documents had recorded at least two incidents in which a mental health patient was discharged from the facility without proper process.

One of those patients was “discharged – against short stay unit home team plan – (and) put at risk of harm to self with inadequate follow up”.

The patient was referred to youth mental health service Headspace.

But the referral was rejected because the patient was “high risk” – and there was no further followup, according to the document.

“Headspace referral was submitted on discharge by on call team, however was rejected by Headspace due to high risk of patient.

“No further follow up was put in place by on call team, placing the patient at significant risk.”

SA Health told InDaily yesterday that “discharge planning is a complex process tailored to the individual patient, with the final decision made by clinicians in consultation with patients and their families”.

“Our clinicians and staff are appropriately skilled and undergo vigorous professional development and mandatory training requirements to ensure patients are discharged at the most clinically appropriate time.”

Mental Health Coalition executive director Geoff Harris told InDaily safety concerns about mental health facilities could discourage people with mental illness seeking help.

“Findings like these run the risk of people not going to … mental health facilities, which creates a range of other risks,” said Harris.

Families and loved ones who have someone in a mental health unit believe that they are in a safe space.

“We do need to provide more support in the community for families and loved ones to help people avoid getting to a crisis point.”

He said the most important area of “long-term strategic investment” for South Australia’s mental health services was in community services.

“There’s a need to focus on governance in health systems in South Australia,” he said.

He added that leaving hospital is a “known risk factor” for mental health patients and that it was vital that services ensure they “provide effective support for people”.

SA Health warned about safety risks in 2015

Mulholland’s December 2017 report on the short stay unit said that the union had warned the unit was “not fit for purpose and was unsafe for both staff and patients” as early as mid-2015.

A June 2015 letter to then NALHN chief executive Jackie Hanson, cited in the report, reads: “The medical staff highlighted a number of industrial and safety issues regarding 1G (another of the hospital’s mental health units) and short stay unit regarding over capacity and in particular the current mental health patient demand impacting on workload and health and safety of staff and patients”.

A failure to ensure appropriate levels of staffing was among the findings of then-Chief Psychiatrist Dr Aaron Groves’ explosive review of the Oakden facility, which forced the Weatherill Government to shut it.

In the ICAC report on the subject, Lander found Hanson had not engaged in maladministration over Oakden, but that NALHN had.

Oakden had received accreditation up until 2019, from the Australian Aged Care Quality Agency, at the time that Groves’ review was made public.

The Lyell McEwin Hospital mental health short stay unit, like Oakden, had been fully accredited by external agencies when SA Health decided it had to be closed.

SA Health InDaily in December last year (the month it closed the facility) that the Australian Council on Healthcare Standards and the Australian Commission on Safety and Quality in Healthcare had accredited it to operate.

“Like all Incorporated Hospitals, the Lyell McEwin Hospital was most recently accredited against the National Safety and Quality Standards 2012 and the National Standards for Mental Health Services 2010 in late 2016,” a spokesperson for the department said at the time.

Unlike the Oakden case, however, there is no evidence of patients suffering abuse and neglect at the hands of staff, or a culture of coverup about the nature of the facility.

Mulholland told InDaily this morning South Australia would continue to see unacceptable treatment of people with mental illness in facilities like the short stay unit and Oakden unless the Government undertook a broad review of its mental health facilities, especially in northern Adelaide and country South Australia.

“We now need to heed the warning signs in the north … to ensure that were is some intense review of these services,” she said.

“(Or) we will continue to see the Oakdens, the short stay units.”

She said there was “a need for federal and state governments to work together to find some resourcing solutions to for impoverished areas most in need … given what’s happened at Oakden and the short stay unit”.

Mulholland said the Northern Adelaide Local Health Network’s mental health services – as well as mental health services in country South Australia – have, for years, been underfunded to provide vital services.

“Culture of complacency”: Greens call for urgent action

The Greens are calling on the Government to take urgent action to ensure mental health services are fit for purpose, and support the doctors’ union’s call for a statewide resourcing review.

Franks told InDaily it should not have taken SA Health so long to close the facility.

“For staff and union voices to go unheeded for such a long time this should ring alarm bells for the new Minister (Mental Health Minister Stephen Wade),” she said.

“He needs to take urgent action to ensure there’s no continuing culture (problem).

“A culture of complacency is just as dangerous and damaging as a culture of coverup.”

She said: “When South Australians seek health care they deserve the highest standards.”

“Given what we know about Oakden, it’s clear that we have to do better in our health system in this state.

“The new Government has the opportunity to make significant improvements.”