Oakden ICAC report: How SA’s health system failed vulnerable aged care residents
“A DISGRACE, a shocking indictment and a shameful chapter in SA’s history” — ICAC Commissioner Bruce Lander has handed down a scathing report into the Oakden aged care home scandal. He strongly criticised former minister Leesa Vlahos but said one thing saved her from a finding of maladministration.
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“A DISGRACE, a shocking indictment and a shameful chapter in SA’s history” — ICAC Commissioner Bruce Lander has handed down a truly damning report into the Oakden aged care home scandal.
Mr Lander QC does not make a finding of maladministration against any government minister.
However he reveals that former mental health minister Leesa Vlahos was one of three people who attempted to prevent him from naming them in his final report, causing “distraction” and “delay”.
The corruption watchdog’s extensive report, released online this morning, makes findings against five individuals, and the broader Northern Adelaide Local Health Network.
Mr Lander singles out senior management staff at Oakden facility and administrative staff in the health system, including those responsible for taking complaints, for findings of maladministration.
The 456-page report, delivered just more than a fortnight before the state election, makes 13 recommendations for change.
“Every South Australian should feel outraged at what happened at the Oakden Facility,” Mr Lander said.
“The consumers at Oakden were poorly cared for, forgotten and ignored.
“What occurred at the Oakden facility is a shocking indictment on its management and oversight. It represents a shameful chapter in this state’s history. It should not have happened. It must never happen again.”
Mr Lander considered 350,000 pages of evidence and described what he found as “astonishing”.
“It pointed to a regime that existed whereby serious complaints about care were not appropriately addressed,” the report states.
“Above all it highlights what can occur when staff do not step up and take action in the face of serious issues.”
Mr Lander’s report finds that the problems at Oakden were “to a large extent ... unknown to ministers and chief executives”.
He particularly criticised Ms Vlahos’ handling of the evolving crisis.
“She did not lead in addressing the crisis. She followed,” the report says.
“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.”
Mr Lander names Northern Adelaide Local Health Network chief executive officer Jackie Hanson as “the only person who took positive action upon becoming aware of the true state of affairs at the Oakden facility”.
“It was Ms Hanson who commissioned the Chief Psychiatrist to conduct the review that resulted in the Oakden report,” he says.
“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. Ms Hanson thereafter kept a close eye on the facility.”
Ms Hanson has since quit SA Health to take up a new role in Queensland.
Mr Lander savages Ms Vlahos’s “assertion that she was the one who commissioned the report” saying it was “not supported by the evidence”.
The report makes findings of maladministration against former Northern Adelaide Local Health network consumer liaison officer Arthur Moutakis and four staff at the Oakden facility itself.
They include a triumvirate of former Oakden staffers — clinical director Russell Draper, nursing director Kerim Skelton and service manager Julie Harrison — who Mr Lander said had responsibility for managing the facility.
Mr Lander also found nurse and practice consultant Merrilyn Penery had committed maladministration.
Ms Harrison and Karim Goel — the clinical services co-ordinator for the two condemned wards at Oakden — were the other two people, in addition to Ms Vlahos, who tried to keep Mr Lander from publishing their names in his report.
Mr Lander had asked to be able to hold hearings for his inquiry in public but was unable to do so because of ICAC secrecy legislation, which the State Government has refused to ease.
In today’s report, Mr Lander again calls for “the discretion to conduct investigations of this kind in public”.
“This investigation has firmly reinforced my view that the legislation under which I operate ought to be amended,” he says.
READ THE FULL OAKDEN REPORT HERE
BRUCE LANDER’S KEY RECOMMENDATIONS
► All staff working in health facilities where mental health services are offered should undergo training in their reporting obligations.
► New Mental Health Minister Peter Malinauskas should commission a report, to be made public, on the “physical condition of all facilities” where mental health services are provided.
► A review should also be conducted into the use of restraints in such facilities, and new standards of use considered.
► The State Government should consider whether more staff are needed in both the office of the Chief Psychiatrist and the Community Visitor, and generally in mental health facilities.
► More frequent, unannounced visits should be made to mental health facilities by the Chief Psychiatrist and Community Visitor.
► The State Government should consider whether the Chief Psychiatrist should be obliged to ensure that people with mental illness receive an “adequate standard of care” in such facilities.
► A review should be conducted to determine if the staff of the Community Visitor should have more specific qualifications in mental health.
► Staff working in facilities where mental health services are provided should be “routinely reminded” of their responsibilities.
HOW THE GOVERNMENT RESPONDED
Premier Jay Weatherill will brief family members of elderly residents who lived at the now-closed home about the findings later today.
Mr Lander examined who received information about complaints made about conduct at the Oakden, what they did, and if action was taken in a timely and appropriate manner.
He launched his Oakden inquiry last year following a harrowing report from former chief psychiatrist Aaron Groves, which uncovered allegations of neglect and abuse, and a culture of cover up, at the aged care and mental health facility in Adelaide’s north-east.
The facility has since closed and residents were moved to a refurbished facility at Northgate.
The State Government has pledged to build a new $14 million home to better meet the needs of elderly residents with mental health issues.
Former mental health and disabilities minister Leesa Vlahos, who was then responsible for the Oakden home, resigned from her portfolio in the wake of Mr Groves’ report, citing health reasons.
Earlier this month Ms Vlahos revealed she would not contest the March 17 state election.
While she did not expect an “adverse finding” in Mr Lander’s report, Ms Vlahos said she did not want her candidacy for the election to “become a distraction” for the Labor Party so close to polling day.
HOW THE SCANDAL UNFOLDED
The Oakden scandal first broke when Chief Psychiatrist Dr Aaron Groves released a damning report into the facility in April, 2017.
It was triggered by the overdosing of former resident Bob Spriggs, 66, who also had unexplained bruises while staying at the home in 2016. He has since died.
Mr Groves’ report revealed patients at the home were over-medicated, physically abused and isolated.
It found medical errors had gone unreported, possessions regularly went missing and staff kept residents on the floor rather than properly dealing with their behaviour.
Other examples of “gross inappropriate conduct” included aggressively washing a resident’s genital area and patients being left soiled and unbathed as well as mocked and ridiculed.
One family member revealed reports that a senior nurse “stomped” on her dad while he was being restrained and the incident was not reported because of “possible ramifications”.
Another resident was given a double dose of medication within two days of being in the facility.
The report also discovered a culture of cover-up and states that staff in the facility did not take responsibility for the unacceptable conditions and regularly said that was up to others.
Three incidents known to have occurred in the eight months preceding the report were referred to police.
Eight staff members were also stood down and 21 reported to the national health regulator for action.
In May last year, Mr Lander criticised a culture in which ministers take “less responsibility” for problems under their watch than in the past.
“They have to have some personal involvement now before they will resign,” he said.
Mr Lander also took issue with ministers, including Mr Weatherill, for referring to his investigation into systemic mistreatment of elderly patients at Oakden as an Ombudsman’s inquiry, adding he suspected it was “to diminish the importance” of the investigation.
The scope of the ICAC inquiry reaches back to 2007, when Oakden failed national accreditation requirements and came under sanctions.
The period of the inquiry covered the tenure of several mental health ministers including Ms Vlahos, former Health Minister Jack Snelling and former minister Gail Gago.
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