What happened at Oakden
I would say that Oakden was a perfect marriage of chaos and
This chapter will detail what occurred at the Oakden Older Persons
Mental Health Facility (Oakden) in the lead-up to the closure of the facility.
In particular, this chapter will focus on concerns about the quality of care
provided to residents in the facility. The chapter will extensively rely on evidence
from family statements from the Adelaide hearing, evidence from staff and
external advisors, and evidence detailed in the investigation by the South
Australian (SA) Chief Psychiatrist.
Complaints from the families of Oakden residents
Case study – Mr Bob Spriggs
In January 2016, Mr Bob Spriggs was admitted to Oakden after 4 months'
hospitalisation in the acute ward at the Repatriation General Hospital (the
Repat). While it was originally intended that Mr Spriggs would be moved to a
secure area in a private residential aged care centre, due to the severity of
his symptoms he only lasted one day in private care before being returned to
the Repat acute ward. At this point, his family were informed that he would
need to be moved to Oakden. Mr Spriggs was relocated to Oakden, accompanied by
staff from the Repat who had prepared a written care plan.
The family did not know anything about the Oakden facility before
Mr Spriggs arrived, but his wife, Mrs Barbara Spriggs, described her first
impressions to the committee:
As a family, we were out there to greet him when he came. It
didn't feel good right from the word go. We didn't appreciate the way that we
were treated when we got there. We didn't appreciate the fact that they were
asking us so many questions about Bob's care and what he needed, because we
knew that there had been a good handover from the Repat. But, that aside, we
just tried to embrace the fact that Bob had to be there, because we were told
at the first meeting how we were very fortunate to get Bob in there, because it
was the only place in South Australia that would take somebody like him, so we
should feel very lucky that he was able to get a place there. They said, 'You
have to tick lots of boxes to get in here, and you've ticked all the boxes,' so
we thought, 'Well, we're probably lucky that he's in here.' But we didn't feel
good about it.
Mrs Spriggs explained how after her husband had been at Oakden one week,
the facility's psychiatrist recommended that Mr Spriggs be returned to the
Repat acute ward '...because things aren't working out here. It's a bit hard to
handle him...he needs a lot more care'. However, when Mrs Spriggs contacted the
Repat, she was told that her husband could not stay there as it was an acute
facility, not an aged care home. This situation left her feeling devastated
about what to do for her husband's care.
The next day, Mr Spriggs was taken by ambulance from Oakden and
readmitted to the Repat acute ward, where Mrs Spriggs was told that her husband
would have to return to Oakden. There was some question of whether there was a
deficiency in the handover between the two facilities, so the family held
meetings with Oakden to address their concerns and try to improve things before
a second transfer. Mrs Spriggs described how the Repat to put together a care
plan and coordinated her husband's second transfer to Oakden some weeks later,
but that alarm bells had begun to ring:
I can't give the Repat high enough marks as to how hard they
worked to put together a package for him to go out there with lots of backup.
They assured me that they would ring every day and offer help. They stayed out
there the whole day the first day that Bob went out there. There were two staff
members that went out with them. I saw them putting information into the
computer. I saw them talking to the whole staff about how to look after him.
They would ring me nearly every day to ask how things were going, and I could
see there were a few things wrong. They said: 'Well, we've rung up and we've
asked, "Can we help you?" but no; they're okay. They were managing.'
During his second stay at Oakden, Mr Spriggs' health and function
rapidly declined. In February 2016, Mr Spriggs was found to have very
significant bruising to one hip and was sent to the Emergency Department of the
Royal Adelaide Hospital to investigate whether this hip was broken. On arrival,
it was discovered that he was dehydrated, was suffering from pneumonia, and had
been overmedicated. He did not return to Oakden following this incident.
Mr Spriggs passed away in July 2016, six months after his first
admission to Oakden.
The Spriggs family has detailed a number of instances of neglect or
failure of care which occurred while Mr Spriggs was a resident of Oakden. These
unexplained bruising, including the bruising to his hip which necessitated
emergency admission to Royal Adelaide Hospital;
severe dehydration and undernourishment; and
being placed/left on the floor when he was 'too difficult to handle',
with a nurse on either side to prevent him from standing.
In addition to these, there was one very serious instance of medication
mismanagement. Mr Spriggs received 10 times the dose of an antipsychotic drug
on at least three occasions, over three sequential midday doses.
Mrs Spriggs explained that she had not realised the implications of this at the
time she was informed:
It went over my head, to be honest, and my heart went out to
the doctor, because we all make mistakes. Looking back, I should have really
jumped up and down, but I just said, 'Okay, well, mistakes happen.'
However, the Spriggs family believes that this medication overdose was a
major contributing factor to Mr Spriggs' rapid decline in function and may have
contributed to his death.
It was noted by the Spriggs family that, as far as they were aware,
neither staff from the Repat nor the Royal Adelaide Hospital made any formal
complaint or report about Mr Spriggs' condition following his admissions from
The Spriggs family first contacted the Community Visitor Scheme (CVS) on
1 June 2016 to raise their concerns about the care environment at Oakden. The
CVS response to the Spriggs family's complaint is discussed later in this
Mrs Spriggs had kept detailed notes and photographs of her husband's time in
care and expressed a motivation:
... to pursue this matter... because she wanted to ensure that
other families would not have to go through what she and [her family] had gone
Evidence from the families of other
There have been many more instances of neglect and failure of care at
Oakden raised by the families of former residents. The committee heard from two
panels of family members during the hearing on 21 November 2017 in Adelaide,
and received 26 submissions from individuals, many of whom are family members
of former Oakden residents. Family members' accounts have featured consistent
themes of feeling betrayed by and distrustful of the public aged care system
following their experience with Oakden; they felt let down by a system which
was designed to help vulnerable people but, in their opinion, had failed to do
As was the case for the Spriggs family, other families reported that
they often had no choice in sending family to Oakden as it was only facility in
South Australia able to care for their family member's needs. Families
explained that private facilities that can accommodate dementia residents,
particularly where there are concerns about violent behaviour, are extremely
limited, and this is supported by evidence from the Oakden report.
Residents were shunted between hospitals or acute care and
Oakden, with neither facility really being suitable for the needs of the
resident. There were some issues around the difference between the acute and
long-term care their family members were receiving across the public health
sector, which reflects the concerns held by CVS about the classification of
Oakden as sub-acute. 
Many family members reported impacts on their own mental health and a
significant burden to continue to provide care for the resident due to the lack
of appropriate personal care provided to residents at Oakden.
Others questioned how staff would feel if it were their parent or loved one in
that centre receiving similar poor quality of care.
The committee was presented with overwhelming reports from families of the
poor quality of personal care at Oakden.
Resident's clothing in the facility often went missing or was put on
other people, and residents were dressed poorly and haphazardly, but staff did
not appear to care.
Despite labelling, clothes would still go missing or be placed on different residents.
Residents were also left in soiled clothing for long periods of time
and were not washed.
Residents were not being fed properly and '[t]he quality of food was
Some residents were not being given opportunity to actually swallow their food
and staff force-fed sleeping residents or residents with known swallowing
One choking incident required emergency hospitalisation for a resident.
Residents were also being restrained for significant portions of the day
and not being walked, resulting in bedsores and worsening health outcomes.
Medication mismanagement and clinical care
Medication mismanagement was common, and this is also detailed in the
Oakden and CVS reports. Many family members reported over-sedation and/or
overdose, leading directly or indirectly to the death of their loved one in
There was a belief that sedation was used as chemical restraint to minimise the
need for care from staff:
That's where, as a culture, everyone just seems to think:
'Oh, they've got mental health issues, so dose them up, overmedicate
them'—which they did for my father—'and just leave them to be. Strap them in a
chair for the daylight hours and then just put them to bed at night.'
In one instance recounted to the committee, an overmedicated resident
was unresponsive for 12 hours before staff called an ambulance. However,
following this adverse event, the resident's family were not sure if there was
any change in staff behaviour at Oakden nor, in an echo of the Spriggs' case,
if the overmedication was ever reported by Royal Adelaide Hospital:
We actually told Royal Adelaide that we felt that dad was
being overmedicated—we know for sure he was being overmedicated. They agreed
with that and they told us that they were going to write a letter to Oakden
because they questioned all the medication. My dad was still on antipsychotic
drugs three years later, and they wanted to know why he was on such high
dosages of all those drugs. We had that family meeting two days later and were
reprimanded, because we overreacted when we walked in and saw my dad completely
unresponsive and we scared the nursing staff at Oakden. We were reprimanded on
that first up, and in the next breath we were told that dad was ready to go to
mainstream—all after Royal Adelaide, supposedly, and I don't know if they ever
did, send a letter about my father's medication.
Families noted that staff often did not have explanations for residents'
unwitnessed falls or bruising,
and in one instance failed to identify a major injury after a fall.
Other families also questioned why hospitals did not report apparent abuse of residents
when comments suggest that the issues at the facility were known to hospital
When my mother was admitted to the [Royal Adelaide Hospital],
the first question was, 'I bet you're from a nursing home and I bet we know
Abuse of residents
There have been accusations of staff perpetrating physical and verbal
abuse against residents, some witnessed and some suspected. There is no CCTV footage
of the centre, so staff explanations for injuries and incidents, such as
unwitnessed falls or bruising, could not be corroborated,
and families reported that complaints were 'brushed off' when made to the
One family reported verbal and physical abuse of a resident by a staff
member in front of the family. In this situation, the registered nurse on duty
did not step in to stop the staff member concerned, and the family were unhappy
with the response:
The police were called; however, no charges were ever laid
against this carer, because the registered nurse that was on duty downplayed
the incident and said that my father had actually provoked the attack. I don't
know how a patient with Lewy body dementia—and yes, my father was aggressive,
but at that point his medication was stable enough that he wasn't. So nothing
ever happened to that carer or to the registered nurse that witnessed the whole
thing and did nothing to intervene.
Administrative concerns, responsibilities
and incident reporting
Many families noted major issues with the administration of Oakden,
particularly in the handover of resident information, which is an area of
significant importance for a facility that was intended to act as a transitory
stage and not long-term care. The committee heard that handover of resident
information and medical history to new doctors or other health professionals
was left to the responsibility of family members
or, even where a full handover had occurred, family were called upon to provide
In one situation, a family member had to intervene to instruct ambulance
staff because Oakden staff would not direct them to a particular hospital for
the resident's emergency treatment. The same family also found they had the
opposite problem, with the facility not contacting them in other situations for
power of attorney issues or to make decisions about medical procedures.
Even when Oakden was closing, there were administrative errors which
nearly saw one female resident transferred to a men's ward at Northgate due to
miscalculation of resident numbers.
Families reported that they were given insufficient information in their
first contact with Oakden, so they did not know who to approach when they had
When they did raise issues or make complaints with management, some families
reported feeling 'fobbed off' or dismissed.
In one case, the family found that after they made complaints, the facility
staff moved to contest their guardianship of the resident.
Additionally, a lack of accountability and shifting of blame between
levels of management and levels of government has left families feeling
ignored, excluded and helpless in their quest to find answers to their
questions and closure in their grief. One witness told the committee about his
concerns about the failure of clinical governance at Oakden and his fear that
reviews, if conducted by the same system which implemented the model of care in
the facility, will not achieve anything:
Nothing will make up for what mum and others went through,
but our expectation is accountability, and the evidence, with exposed time
lines and reported failings have been uncovered thus far throughout many
inquiries, shows without doubt that there were identifiable and culpable people
who either in the past or still currently do via the position they held or hold
either actively sought to cover up, encourage or, at the very least, fail to
execute their duties. This facilitated and allowed a systematic abuse of
procedure and through inaction and maladministration actively and successfully
created and continued to develop a culture of bullying, intimidation and
corruption with outright, blatant criminality. This also allowed blame shifting
and zero accountability to become the norm at all levels of SA Health and other
industry overseers. These individual people, including ministers of government,
CEOs and senior bureaucracy within departments, whether in a past appointment
or tenure or a current one, were and are responsible through the position they
held, and it is already unequivocally clear where and with whom the chain of
command started and finished...Inquiries and investigations ordered politically
as a result of adverse events being exposed are legendary. So are the resulting
actions in administering and implementing findings. Why? Generally those at the
top commission the very same negligent framework of people and personalities to
implement the findings, or be seen to, with a large implementation window of
The concerns raised by family members raise fundamental questions
regarding the model of care under which services at Oakden were delivered.
The model of care at Oakden
...Model of Care is defined as the way that health services are
delivered, drawing on best practice care and services for a person, population
group or patient cohort as they progress through the stages of managing a healthcare
condition. A Model of Care articulates how people can access the right care, at
the right time, from the right team in the right place.
Oakden was originally established in 1982 by the SA Government as a state
government funded health facility, delivering a specialist mental health
service for older people with severe mental illness, including mental illness
arising in the context of dementia. From 1998 onwards, although the service
remained the same, part of the facility was reclassified as an aged care
service so that it became eligible for Commonwealth aged care funding. This
lead to confusion in the health system about resident eligibility, regulatory
and the complex arrangements for resourcing and funding between the State and
Additionally, classification as an aged care facility rather than a special
mental health service meant a lower staff to resident ratio was required by the
relevant accreditation process.
Oakden primarily provided care for older people with enduring or severe
mental illness in need of transitional care and people with severe Behavioural
and Psychological Symptoms of Dementia (BPSD) rated at Brodaty Tier 6 (Dementia
with very severe BPSD) or Brodaty Tier 7 (Dementia with extreme BPSD), and who
were unable to receive care in non-government dementia-specific aged care
2.1–Seven-tiered model of management of behavioural and psychological symptoms
of dementia (BPSD)
Source: Medical Journal of
Evidence received by the committee has shown that the model of care in
place at Oakden was out of date and not updated to reflect modern approaches to
dementia and other ageing-related cognitive and mental health issues.
Older persons mental health in SA
Prior to 2012, there was no model of care developed for the care of
older people with severe mental illness in SA, although project teams and
reference groups tasked with developing such a service model had been
established in 2007. A draft model, designed to respond to national policy
changes, mental health reform and state initiatives, was endorsed by the SA
Older Persons Mental Health Services (OPMHS) in 2012 but was not endorsed or
progressed by SA Health.
That draft model of care:
...articulated a number of underpinning principles including;
the uniqueness of the individual; having real choices; fostering recovery
oriented attitudes and rights; dignity and respect; partnership and
communication and evaluating recovery.
This draft model set out two types of mental health units of relevance
to Oakden, each designed to deliver 'high-dependency but recovery-focused
specialist care' before transition to mainstream care:
Transitional Care Units (TCUs), which would act as transitory care
(average length of stay 3–6 months) for step-up/step-down between acute
facilities and mainstream aged care; and
Intensive Care Behavioural Units (ICBUs), which would act as slow-stream
units (average length of stay 18 months) for residents whose behavioural and
psychological symptoms could not be managed in mainstream aged care, even with
The model of care recommended that TCU and ICBU beds be available in all
local health networks to ensure service proximity to families, carers and
It also proposed contractual arrangements between state government and
non-government organisations (NGOs), wherein a NGO would host the service and
OPMHS would manage admission/discharge and 'provide extensive control over
assessment, care planning, therapy, medication management, research and
education through an in-reach model led by the Community Mental Health Team'.
This proposal was consistent with the SA initiative Stepping Up: A social
inclusion action plan for mental health reform 2007–2012 recommendation
that TCU and ICBU beds be outsourced to the non-government residential aged
The Oakden report findings on model
While the 2012 OPMHS draft model of care holds similarities with other
states' approaches to TCU and ICBU bed classification, the proposal to transfer
these services to NGOs was specifically addressed as a major concern in the SA
Chief Psychiatrist's Oakden Report – The report of the Oakden Review (Oakden
report). It was unclear why the NGO outsourcing of these services was proposed,
beyond an overall push within the OPMHS to reform the sector in SA.
The Oakden report detailed evidence from New South Wales, Victoria and
Western Australia which suggests that Tier 7 BPSD beds should only be supported
by state services to ensure consistent access to specialised, highly-trained
staff. Furthermore, there are no specific Tier 7-only services provided by the
residential aged care facilities in Australia. Additionally, where Tier 6 BPSD
beds are provided in private facilities:
...these are heavily subsidised by the State Government (in
addition to the Commonwealth subsidy that is received) to ensure the person...has
access to the full range of highly trained multi-disciplinary staff needed to
ensure safe, high quality care.
The SA Chief Psychiatrist noted that a lack of an endorsed model of care
was a significant factor in the decline of services at Oakden:
As a result of no endorsed system wide Model for OPMHS there
has been understandably, little done to define a Model that is specific for
Oakden. This has led to a resultant further decline in services at Oakden
Campus, which remains unclear what its purpose is within a State-wide system of
As such Oakden has continued to provide services that should
be consistent with TCUs and ICBUs, on behalf of the State, without a plan that
supports the level of resources it needs to provide such a service.
This is compounded by a widespread view, held by the staff,
which the Review heard repeatedly, that Oakden (in particular Makk and McLeay
Nursing Home), is a place for the rest of the consumer's life. This resulted in
an attitude among staff that there was less effort and emphasis that needed to be
placed on managing the consumer's challenging behaviours as there was little
prospect that any improvement would help facilitate their discharge. This
became a self-fulfilling prophecy for many in Oakden.
The SA Chief Psychiatrist also made a number of significant findings in
the Oakden report in relation to the model of care in place at the facility,
concluding that 'Oakden is not providing the right care, at the right time from
the right team'.
The Oakden report found that at the time of the review:
there was no specific, satisfactory model of care that had been
developed for the types of services provided at Oakden;
there was no articulation of who would be provided services at Oakden or
how those services would be achieved regarding staffing, resources and
that local health networks across SA relied on Oakden to provide services
for sub-acute and acute BPSD services and transitional care, rather than making
arrangements for these services in their own catchment areas;
that the unendorsed model of care proposed by the executive leadership
of the SA OPMHS in 2012 was not supported by 'the degree of commensurate change
within...resources; skills and capacity; or changes in practice...if the changes
aspired to...were to be achieved' and was therefore 'unable to prevent ongoing
deterioration in the Oakden service';
that this unendorsed model had been relied upon by OPMHS and that the
disconnect between 'an unfunded aspirational document and the real-world
challenges of the service' had contributed to deficits in service at Oakden;
that this unendorsed model did not reflect international or national
best practice in the provision of care for Tier 6 and 7 BPSD; and
that the model of care provided at Oakden did not reflect best practice
for people with functional mental illness and had 'no relationship' with best
practice for people with Tier 6 and 7 BPSD.
Another significant concern with the model of care in place at Oakden
was the physical environment and infrastructure of the facility. The Oakden report
found that the facility itself was 'not well designed or modern for the time it
was built' and, at the time of reporting, was 'entirely unsuitable' as a
facility for management of Tier 6 and 7 BPSD. Furthermore, the substandard
quality of the facility's infrastructure was identified as a cause of low
morale for staff, distress for the families of residents, and had likely caused
'considerable difficulty' in providing appropriate care for the challenges
associated with managing the more severe behaviours of BPSD.
Concerns about the care provided by staff at Oakden
The longstanding push to outsource Oakden's services to NGOs, a culture
of under-resourcing within the facility and a model of care which was
inappropriate, unendorsed and poorly implemented were significant contributing
factors to the quality of care provided in the facility. Evidence received by
the committee in particular shows ongoing concerns, detailed below, about
appropriate levels for staffing and resourcing at Oakden in the years leading
to its closure and the impact of these on the care and treatment of residents.
The Community Visitor Scheme
The CVS was established in 2011 with a role to visit and inspect acute
mental health facilities in SA, including the Oakden facility, every month. Two
community visitors conduct each visit and provide a written report to the
mental health coordinator and the Principal Community Visitor (PCV), which are
then assessed for any issues or concerns.
The PCV, Mr Maurice Corcoran, explained the visiting process to the committee:
We say to all our visitors when we're preparing and going
through our training that when they're visiting and inspecting units that they
run the mum test over it, which is basically that if they are going to look at
the facility, the key part of it is a human service. So it is looking at the
observations between staff, patients and family members, and how they're being
cared for and being treated, but also to look deeply into such things as
individual care and treatment plans.
Where issues or concerns were identified, CVS collate these and forward
copies of reports to the senior executive or directors responsible for the
services in question to seek their response. Recurrent issues are tracked
through a register and raised with an advisory committee, and significant matters
are ultimately included in the CVS annual report, which is provided to the
Mr Corcoran told the committee that CVS had held concerns about Oakden
since beginning visits in July 2011, particularly in relation to a perceived
'streamlined and trimmed down' workforce 'in readiness for a possible tendering
out to the non-government sector':
That was made clear to us in the very early days. That had an
impact on staff and the uncertainty for staff. And that affected the number of
agency staff that were brought in on a regular basis to work at Oakden. That is
very relevant. That placed enormous pressure on a number of other staff we met with—regular
and permanent staff—who were responsible for a lot of the data entry and the
recording of incidence and issues on their Safety and Learning System.
In 2013, CVS visitors reported shortages of mental health nurses,
including positions not being backfilled while other staff were on leave, and
the impact of this on resident care: '[t]hey tried to avoid toileting patients
if some staff were at meetings or meal breaks or not available to help'.
It was also reported that staff did not have time to engage with patients
except to provide tea and fruit.
These concerns about staff and resources were reflected in a number of
visitor reports to the PCV
and raised across a series of CVS annual reports in the lead-up to the Oakden
The CVS annual report for 2014–15 noted that key allied health staff positions
at Oakden were vacant, including the psychologist, who had responsibility for
behavioural plans, and the social worker, who had responsibility for finding
appropriate accommodation for residents. CVS also identified that Oakden was
classified as a sub-acute facility and was therefore using a ratio of 1 staff
member to 4 residents, while acute units would use 1 staff member to 3 residents.
At the hearing on 21 November 2017, the PCV told the committee:
They were getting some of the most complex and challenging
clients from acute wards, which have staffing ratios higher than what Oakden
had as a subacute ward, yet it was expected to cope with and manage and support
people with some of the most challenging behaviours of all. It was classified
as a subacute model of care, a longer term subacute model of care. It was
something that, again, I failed to understand why it was so when we were
dealing with some of the most challenging clients. It was certainly something
we tried to seek answers to.
The committee notes that at the time of the 2014–15 annual report, CVS
had received concerns from three families about the care and treatment of their
family members at Oakden, reporting falls, bruising, medication errors,
sleepiness and drowsiness, and decline of daily function.
In 2015–16, CVS reported that the psychologist and social worker
positions were still vacant. CVS commended the dedication of senior leaders and
managers working at the facility, but held concerns for the pressure placed on
them to cover the responsibilities which the allied health staff had managed.
Concerns received about the care of residents in the previous year were
restated and it does not appear that they received any new complaints in 2015–16.
However, the report also made specific reference to complaints raised with the Minister
about the care of a resident, now understood to be Mr Bob Spriggs, in an older
persons' mental health facility.
Additionally, the report made a recommendation that a review be conducted 'of
the clinical hours in contrast to resident acuity at...Oakden to ensure the
provision of quality and safe care to residents residing in this facility'.
The CVS annual report for 2016–17 presented a worsening situation for
allied health in the facility. At the time of the annual report, the only
allied health professional working at Oakden was a part-time dietitian. An
extract from a visitor report stated that there was no occupational therapist, physiotherapist,
psychologist, speech pathologist, or social worker employed by Oakden and that
while these services were available on call from another centre, staff had
'been told to call on these only in exceptional circumstances...and only two
referrals [had] been made in...18 months (one forensic)'. The report also reiterated
CVS' ongoing concerns about the classification of the facility as sub-acute and
impact of this on staffing levels and funding, despite most residents entering
the facility from acute wards.
The CVS annual report for 2016–17 also included the first reference by
name to the Spriggs family and their complaints about the treatment of Mr Bob
Spriggs at Oakden. The report detailed how CVS had facilitated a formal
complaint process regarding this case to the management of Oakden, before
escalating the matter to the Minister for Mental Health. As discussed in Chapter
1, this sparked the series of events which led to the SA Chief Psychiatrist's Oakden
report and the subsequent closure of the facility.
The Oakden report findings on quality
and safety of care
The SA Chief Psychiatrist outlined a number of serious failures across
all components of the clinical governance framework at Oakden and reported a
number of very concerning findings about the quality and safety of care
provided, including but not limited to:
warning signs, such as rate of injuries, medication errors, poor
documentation, clinical deterioration etc., were not heeded;
there was no ownership of responsibility for clinical outcomes and no
one was clearly in charge;
there was poor leadership and poor understanding of what was expected of
education, training and professional development was 'seriously
deficient and focussed in areas that [were] out of date and irrelevant';
staff were unclear of priorities and focus was on compliance and accreditation,
not on improvement or on high quality and safe care;
staff were afraid to report errors due to fear of blame and because
senior staff 'thought it better not to know';
staff continued to make mistakes because the culture of the facility did
not support learning from mistakes;
clinical risk was not appropriately resolved on the rare occasions it
was raised, leading to staff reluctance to raise concerns again in the future;
external scrutiny was discouraged, open disclosure was rare, professional
accountability was weak and inconsistent;
standards of care were poor and not closely monitored;
safety Learning System data was treated 'as a chore' rather than as a
tool for learning and change; and
information about residents was not actively gathered from families and
carers and complaints were not used as 'a source of important information to
aid improvement' but as seen as part of the nature of the work.
Other concerns about staffing and
The committee also heard evidence from staff, external advisors and
family members of residents about the quality and safety of care at Oakden
which echoed the accounts in the CVS and Oakden reports.
A significant amount of evidence points to consistent understaffing of
the Oakden facility, both in relation to its classification as sub-acute and
due to the perceived streamlining of positions.
This was also noticed by residents' families.
Ms Jackie Hanson, CEO of the North Adelaide Local Health Network (NALHN), of
which Oakden was part, told the committee:
Retrospectively, I would accept, with the contemporary model
we now have, that the nursing hours per patient day that were negotiated and
approved by the ANMF don't deliver the model of care that we now have in place,
which is that of dealing with older people with severe behavioural disorders
and/or enduring mental illness.
Many people also reported that the nursing staff employed by Oakden were
not adequately or appropriately trained for the kind of work they were doing.
Historically, Oakden had been predominately staffed by mental health trained
nurses, not aged care nurses.
The committee heard that a contributing factor towards the lack of
available, qualified staff is that people aren't interested in working in this dementia-specific
area of aged care,
nor are they generally trained in it through a standard nursing degree or other
The CEO of NALHN told the committee that while NALHN had delivered some
training programs to staff at Oakden about resident behaviour and de-escalation
of violent situations, that training was of a 'baseline' nature and was not
reflective of contemporary best practice.
Family members noted how little training was required for some carer
positions at Oakden. Families noted that staff often have no training in
dealing with dementia patients
and are immediately placed 'on the front line' in the dementia ward.
One person noted that it takes just
four weeks in a classroom and three weeks' placement in a facility to achieve a
Certificate III level qualification as a personal care assistant.
Culture and attitudes
As also discussed in the Oakden report, there was a serious concern
about the attitudes of many staff members and the culture created by the view
that the facility was 'for life' and was the only option available to residents:
It was accepted that if somebody was admitted to Makk and
McLeay it was because no other facility would take them due to behavioural
issues. Therein lies part of the problem. Staff had this view that the relatives
should be grateful that we had them because nobody else wanted them.
The committee heard from a former staff member of Oakden, Ms Sharon
Olsson, who detailed many toxic aspects of the nursing and management culture
in the facility, including:
lack of leadership/support from leaders;
lack of understanding among staff about dementia;
'cover-up' when concerns were raised by staff, although this was 'more
at the senior level than the base level';
inappropriate rostering of staff with no background in aged care; and
staff being sent to Oakden as 'punishment' when they had caused problems
at other facilities.
Ms Olsson also described how the facility was a physically unsafe
nursing environment due to broken and run-down furniture, equipment and rooms,
and these comments were also reflected in descriptions of the facility from
and in the Oakden report.
This is likely to have contributed to frustration.
Ms Olsson's comments about Oakden being used as a place of punishment
for bad staff was also reflected in evidence presented to the committee that
there was a large concentration of problem staff at Oakden. One family member
described Oakden as a 'dumping ground', stating that staff were 'unexperienced
and short of patience, and...most of them would never, ever be employed anywhere
Family members of residents stated that staff displayed abusive
behaviour towards each other,
or would blame each other for mistakes.
There appeared to be a culture of lying openly to family members.
Families also told stories of staff 'slacking off' on the job, such as staff
members using a mobile phone for a personal call during medication dispensing
or sitting around smoking outside rather than answering the door or caring for residents.
However, the committee also heard evidence that not all staff at Oakden
were problems for the facility. Some individual staff members offered small glimmers
of hope for family members, who described how they would feel most comfortable leaving
their loved ones behind when those staff were on duty.
Dr Thomas Stubbs, Chair of the Oakden Response Oversight Committee, also
...we should not forget that despite all the horrors of Oakden
there are a lot of very dedicated and very good staff who did a great job. That
needs to be remembered in all of this.
The one thing I would change...
During the course of the hearing on 21 November 2017, members of the
committee asked the witnesses appearing in the family member panels to outline
the one thing they wished they could change about aged care following what had
happened at Oakden. Recommendations and suggestions from families included:
- independent reviews of aged care facilities;
sufficient funding for appropriate mental health aged care facilities,
including funding for sufficient beds in more than one location;
a reporting hotline for the aged care sector;
appropriate training for staff, including on-the-job training in
fixing the culture of mental health and aged care, particularly in
relation to respect for residents;
more information for families about advocates, complaints mechanisms,
and consumer rights;
encouraging a greater understanding of dementia and related issues.
The committee notes that many of these recommendations from family members
reflect those found in reviews and responses from the Commonwealth and SA
governments, detailed in the next chapter.
Evidence presented to the committee shows that the Oakden facility failed
to provide an appropriate model of care: it was not the right care at the right
time from the right team in the right place. This was manifest in facilities
and attitudes of decades earlier, care that did not reflect national or
international best practice and the total lack of an endorsed model of care for
older person's mental health in SA.
The committee wishes to note that while this inquiry has not delved
deeply into the appropriateness of mental health services provided at Oakden, it
must be considered that the model of care issues found at Oakden will become
increasingly relevant to aged care service delivery around Australia, with the
increasing rates of dementia in our ageing population, and the increasing use
of mixed-model services, where specialist mental health and dementia services
are provided within the context of a mainstream aged care service.
The committee agrees with evidence from submitters and witnesses that
poor or inappropriate training and a culture of fear, silence and cover-up
among staff were major contributors to the inadequate care provided to residents
at Oakden. In addition, perceptions that the Oakden facility would be
outsourced to an NGO and categorisation of the facility as sub-acute meant there
were too few staff to manage care in accordance with modern standards.
Most of all, the committee is deeply concerned that warning signs in
relation to resident health were not heeded, such as unexplained bruising,
medication mismanagement and falls, and that complaints from family members and
community advocates were ignored.
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