Once again, it was not the regulators, but a community
visitor whose complaint about Oakden resulted in an independent outside report
that exposed what had been happening at the regularly accredited Oakden.
Chapter 1 provided an overview of the history of the Oakden Older
Persons Mental Health Facility (Oakden), and a timeline of the key events that
led to the exposure of the sub-standard care being provided. Chapter 2 has
provided details about the treatment endured by residents of Oakden. This
chapter will review the responses to date from the relevant government entities
with management and oversight responsibilities for Oakden.
In order to review the adequacy of the responses of the South Australian
(SA) Government and the Australian Government, it is useful to establish a
summary of the various funding, management and oversight responsibilities. While
the Oakden facility was a SA Government owned and managed facility, the
Australian Government Department of Health (Department of Health), Australian
Aged Care Quality Agency (Quality Agency) and Aged Care Complaints Commissioner
(Complaints Commissioner) all play a role in ensuring standards of care in aged
care facilities, and in identifying issues of concern and responding to
complaints. The following table provides a summary.
Table 3.1–Aged care responsibilities
||Funds the majority of aged care (around $17.5 billion in
2016–17) and regulates aged care service delivery to ensure that older
Australians can access safe and quality care.
|Department of Health
||Australian Government department. Administers the Aged
Care Act 1997, including funding for aged care providers.
Based on information provided by Quality Agency,
Complaints Commissioner and the public, determines if Accreditation Standards
have been breached and can educate the provider, issue a notice of
non-compliance or impose sanctions.
||Australian Government agency. Reports to the Australian
Government Minister for Aged Care.
Independently resolves complaints about Australian
Government funded aged care services and educates providers about the best
ways to handle complaints.
||Australian Government agency. Reports to the Australian
Government Minister for Aged Care.
Accredits residential care services in accordance with the
Quality Agency Principles, and the Accreditation Standards made under the Aged
Care Act 1997.
|Northern Adelaide Local
Health Network (NALHN), SA Department of Health (SA Health)
||Approved provider of the Oakden Older Persons Mental
Health Service (Oakden). At the time of critical care incidents, had full
Source: Aged Care Complaints
Commissioner, Submission 7 and Department of Health (Australian
Government), Submission 37.
SA Government actions
The timeline of events provided in Chapter 1 indicates that there was
not a swift response to the Spriggs family complaint from the SA Government.
Evidence presented by the SA Principal Community Visitor shows the agreement from
NALHN to meet with the Spriggs family came after there was media attention to
the publication of details about the complaint, which was then six months old. This
evidence also points to the SA Chief Psychiatrist not responding to initial requests
from the SA Principal Community Visitor to investigate the Spriggs family
However, when action was finally taken by NALHN and the Chief
Psychiatrist, it was comprehensive. After meeting with the family on 20
December 2016, the Chief Executive Officer (CEO) of NALHN commissioned the SA
Chief Psychiatrist to formally investigate service delivery at Oakden, which
ultimately resulted in the closure of the facility and the establishment of an
oversight committee to advise on the development of contemporary older persons'
mental health services.
Despite taking this action, the SA Government did not notify the Quality
Agency that the review was taking place, or that SA Health had formed such a
serious view on the quality of care being delivered at this Commonwealth-accredited
aged care facility. The first time Australian Government agencies became aware
of the review being undertaken by the SA Chief Psychiatrist was on 17 January
2017 via media reports.
NALHN also advised the Department of Health about the review at a meeting on 20
March 2017 regarding the sanctions that had been put in place by the Department.
The Oakden report
The review of services at Oakden was conducted by the SA Chief
Psychiatrist, Dr Aaron Groves, in the first quarter of 2017. The Oakden
Report – The report of the Oakden Review (Oakden report) was released on 20
April 2017 and made the concerning finding that:
...the Oakden facility is more like a mental institution from
the middle of the last century than a modern Older Person's Mental Health
The Oakden report found service and care deficiencies in the following
Inappropriate Model of Care: there was no satisfactory,
specific Model of Care for the types of services provided at Oakden.
Poor infrastructure: Oakden was entirely unsuitable for
its current purpose. The substandard quality of the infrastructure was likely
to have led to considerable difficulty providing appropriate management of the
most severe challenging behaviours of Dementia.
Staffing concerns: there was not an accurate staffing
profile linked to an appropriate Model of Care, staff lacked training
opportunities, staff lacked knowledge on reporting elder abuse and there was a shortage
of trained mental health nurses and Allied Health staff.
Governance failures: there was a failure of governance,
particularly across all components of a Clinical Governance Framework, leading
to poor levels of clinical care across a broad range of areas.
Toxic culture: the dominant culture was characterised by:
poor morale, disrespect and bickering, secrecy, an inwardly looking approach,
control, a sense of entitlement and indifference.
Restrictive practice: staff working did not have the
sufficient level of training in restrictive practices, leading staff to use
restrictive practices beyond those outlined in the relevant legislation
The Oakden report made six detailed recommendations around the issues
developing a specialised contemporary model of care for people over 65
years of age who live with the most severe forms of disabling mental illness
and/or extreme behavioural and psychological symptoms of dementia (BPSD);
provision of appropriate infrastructure to implement the model of care;
developing a staffing model that utilises the full range of members of a
developing a new and appropriate clinical governance system;
ensuring there are people in senior leadership positions that can create
a culture that values dignity, respect, care and kindness for both consumers
and staff; and
- developing an action plan based on Trauma Informed Principles and the
six core strategies developed by the National Centre for Trauma Informed Care,
with a goal of reducing the use of restrictive practice.
The Oakden report made the following key conclusion:
At the very heart of the intent of this report's
recommendations is that Oakden must close and that it must be replaced by a
range of contemporary services that aspire to excellence in care to the most
vulnerable people in South Australia. But more fundamental should be the lesson
that the failings of Oakden should never happen again.
In addition to findings on the sub-standard services provided at Oakden,
the Oakden report also commented on regulatory oversight processes, finding
that there were many practices at the facility 'that no accrediting body would
ever endorse, if it was aware of its occurrence'.
The Oakden report found that Oakden developed a culture of making
periodic attempts to meet accreditation standards, that staff were trained in
what to say during accreditation visits, and that service problems which were
identified in 2007 were present throughout the last 10 years. The Oakden report
It is an important lesson for all involved in trying to
ensure that the best care is provided that reliance only on periodic reviews,
such as accreditation, leads to a sense of comfort that may not be meritorious.
Response to Oakden report – SA
While the Oakden review by the SA Chief Psychiatrist was underway, NALHN
undertook a number of immediate actions to improve the service at Oakden,
employing a new clinical practice coordinator with extensive
experience in aged care and dementia care to provide clinical and operational
oversight at Oakden;
an increase in hours of the consultant psychiatrist;
the engagement of three after-hours registered nurses;
the employment of a part-time social worker and occupational
the employment of a nurse adviser to provide high-level
regulatory independent advice to management; and
the employment of a senior clinical pharmacist and part time
On the release of the Oakden report, the SA Government announced it
would implement all six recommendations of that report.
SA Health established the Oakden Response Plan Oversight Committee (Oakden
committee) in June 2017 'to provide oversight and guidance to SA Health in
implementing the six recommendations outlined in the Oakden Report'.
The Oakden committee further established six expert working groups to
implement each of the Oakden report recommendations.
The expert groups are made of 'a mixture of external people and internal
people, experts in the particular field and in particular a lot of people with
Below is the list of working groups, and their key outcomes as of
15 December 2017:
Model of Care Expert Working Group: draft new model of
care submitted to the Chief Executive, SA Health for endorsement.
New Facility Expert Working Group: has developed a
Schedule of Accommodation (SOA) which is based on the Models of Care Project.
Staffing Expert Working Group: nearing completion of a
recommended staffing profile for Neuro-behavioural Unit. In early 2018 will
prepare a staffing profile for the Specialist Residential Units and the
community-based Rapid Access Service.
Quality and Safety Expert Working Group: draft Clinical
Governance Framework under consideration and consultation.
Culture Expert Working Group: focus groups will convene
in January 2018 to guide the development of a culture framework that will
address and promote respectful behaviours, values-based leadership, effective
problem solving and positive communication.
Restrictive Practices Expert Working Group: completed an
implementation plan for a comprehensive program to reduce restrictive
The SA Government subsequently decommissioned the Makk and McLeay wards
at Oakden and relocated all residents into the Northgate Aged Care facility and
the residential aged care sector.
The SA Government has since allocated $14.7 million to construct a new
older persons' mental health facility. This amount includes $1 million to develop
the contemporary model of care and undertake longer term service planning, on
which the new facility will be based.
SA Independent Commissioner Against
The Oakden report and the Australian Government commissioned review,
discussed later in this chapter, found that despite clear warnings signs, and
in some cases formal complaints, there was a lack of action from all levels of
the administrative and oversight systems within the SA Government and
Australian Government. Evidence presented to this inquiry by a former staff
member at Oakden concurs with those findings:
It was so demoralising. We weren't sleeping and our health
was being affected. We did try and see the Commonwealth department of ageing,
and that just got us nowhere. There were commiserations with the ED, because they
had a minister to report to...I said, 'We're not going to go anywhere. Let's go
to the health rights commissioner,' ...but were told that she didn't have the
resources to help us, that we weren't really going to get anywhere and we
should look after our own careers. So, with that, feeling totally demoralised,
having failed at making the changes that I was to make—and I've never had this
situation before—I left. I went back to my substantive position, because I knew
I couldn't cope with it any longer.
Family members of Oakden residents who have closely followed the various
reviews have expressed similar views:
[T]here 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.
In response to these issues, the SA Independent Commissioner Against
Corruption (SA ICAC) is conducting an investigation into incidents at Oakden.
In announcing the investigation on 25 May 2017, the SA ICAC stated:
[The investigation] will focus on the extent to which all
people in authority, from local management to executive leadership and
Ministers, were aware of the conditions and sub-optimal care being delivered at
the facility, when they became aware of such information, and what if any
action was taken in response to that information. Alternatively, if information
did not become known to appropriate persons in authority, my investigation will
enquire as to why and how this may have occurred.
The terms of reference for the investigation include whether appropriate
complaints mechanisms were in place, whether complaints were brought to the
attention of senior staff or SA or Australian Government officers and what
actions were taken, whether anyone took steps to 'cover up' reports of poor
The SA ICAC stated the findings of the investigation would be published if it
was 'in the public interest'. There is no set date for completion of the
investigation or subsequent possible publication of the findings.
As of September 2017, nine former Oakden staff were referred to SA
Police for investigation, triggered by the SA Chief Psychiatrist's report.
In December 2017, a former Oakden staff member, working at the Northgate
facility where many Oakden residents were transferred to, was reported to
police for alleged assault relating to the use of restrictive practices. As
part of the subsequent police investigation, it was discovered that two other
cases of assault occurred within six months, with one case taking five months
before it was reported to police by the facility.
Whilst noting the findings of the SA ICAC investigation will be only published
if it is in the public interest, the committee is of the view that these
findings are likely to be pertinent to any broader recommendations this
committee would wish to make on appropriate quality oversight and regulation of
the aged care sector.
Australian Government responses
As outlined previously in this chapter, the Australian Government was
not notified of the serious concerns with quality of care that the SA
Government had formed regarding Oakden. In response to the care issues at
Oakden coming to light via the media, the Australian Government took two key
steps. First, the Minister for Aged Care, the Hon. Ken Wyatt AM, MP, announced
an independent review on national aged care quality regulatory processes.
The outcomes of the review report, Review of National Aged Care Quality
Regulatory Processes (Carnell Paterson review), was published in October
2017 and made ten recommendations. As a second step, the Australian Government
immediately moved to implement recommendation 8, unannounced audit visits,
while it considered the entire review in detail, a process still underway at
the time of drafting this interim report. The findings of the report are
discussed in greater detail later in this chapter.
Quality Agency actions
Concerns raised throughout this inquiry with Quality Agency processes in
relation to Oakden centred on the Quality Agency audit of March 2016, where
Oakden was found to have met all Accreditation Standards and was accredited for
a further three years.
This was one month after Mr Spriggs had been admitted to hospital with
unexplained bruising, dehydration and an untreated chest infection.
The committee heard evidence that consultants who were hired to improve
services at Oakden also did not understand how Oakden was able to pass
accreditation audits despite longstanding issues of concern with service
The same consultants told the committee of the serious consequences of Quality
Agency failures to identify poor service outcomes at Oakden:
Normally in an organisation those little things might not
have been big. But in this case it actually supported institutionalised elder
abuse. And that's what Makk and McLeay were, make no mistake.
There is also evidence that the recommendations of auditors were not
always taken on board by the Quality Agency in relation to Oakden. In January
2008, the Quality Agency considered whether to continue Oakden's accreditation
following a December 2007 audit finding that 26 out of 44 expected outcomes
were not met. The assessment team that had conducted the evaluation recommended
that the facility not be accredited and the Quality Agency considered this
along with other factors, such as NALHN's response to the assessment report and
actions which had undertaken since. The Quality Agency set aside the audit team's
recommendation, describing its decision in a letter to NALHN on 7 January 2008:
The assessment team also recommended that the Agency revoke
the home's accreditation. In making its decision, the Agency considered the
home's level of noncompliance, compliance history and the home's remaining
period of accreditation. While the home still has non-compliance, the Agency is
satisfied that the home is continuing to make improvements to ensure the
health, safety and well-being of residents. 
The CEO of NALHN pointed out that despite the failings at Oakden now
being recognised as longstanding, Oakden received full Quality Agency
accreditation in 2010 and at every subsequent audit a full three year
accreditation cycle was granted. The CEO of NALHN told the committee:
In fact, as recently as February 2016, Makk and McLeay passed
all 44 expected outcomes under the Commonwealth Accreditation Standards and
received a three-year accreditation period. Makk and McLeay also received an
unannounced visit from the Commonwealth auditors in October 2016, and passed
that assessment as well. At no time were concerns raised with NALHN in relation
to systems and processes on any of these occasions until the audit conducted
between 6 March 2017 and 17 March 2017, following the announcement of the Chief
Psychiatrist's Oakden review.
Of significant concern, is that the Quality Agency also conducted an
assessment contact visit to Oakden as late as November 2016, and Oakden was
found to have met all assessed expected outcomes.
However the findings of the next audit were significantly different. After
the Spriggs family complaint become public knowledge and the SA Chief
Psychiatrist undertook an investigation into Oakden, the Quality Agency conducted
another audit of the facility. On 28 February 2017, 12 months after the
previous audit and a mere four months after the unannounced contact visit, the
Quality Agency undertook an audit which included examination of incident
reports and medication charts. That audit used two assessors as distinct from
the previous audit which used a single assessor. The report of the February
2017 audit raised a number of issues of concern which instigated a review audit
in March, a rare occurrence that is indicative of potentially serious issues at
a facility. The review audit was conducted by three assessors over a fortnight
and found that residents were not being provided with adequate care and that
the facility had failed 15 of the 44 Accreditation Standards.
The Department of Health then determined an immediate and severe risk to
residents and imposed the following sanctions:
approved provider is not eligible to receive Commonwealth subsidies for any new
care recipients for a period of three (3) months.
of approved provider status, unless an adviser, is appointed by the approved
provider for a period of six (6) months, at its expense, to assist the approved
provider to comply with its responsibilities in relation to care and services.
of approved provider status, unless the approved provider agrees to provide
relevant training within six (6) months, at its expense, for its care staff,
managers and key personnel to support it in meeting the needs of care
Reason(s) for sanction:
The department identified that there is an immediate and
severe risk to the health, safety and wellbeing of care recipients at the
service following information received from the Australian Aged Care Quality
Agency (the Quality Agency). The department has serious concerns in relation to
deficiencies in medication management,
failure to follow medical and allied health instructions and as a
result placing care recipients at risk of injury or decline in health status,
care recipients not receiving correct medications, including
overdose and significant delays in receiving medication, and
lack of clinical supervision and monitoring at the service.
The Quality Agency subsequently undertook a series of actions to
investigate why Oakden passed the March 2016 audit, when it later failed the
March 2017 audit. The CEO of the Quality Agency told the committee:
[T]here is no doubt that the quality agency has some
significant learnings to take away from the failures at Oakden.
In discussing why the March 2016 Quality Agency audit did not identify
concerns with the quality of care at Oakden, the Quality Agency told the
committee that key information from previous audits was not adequately taken
into account in later audits, and that there were improvements to be made in
how the Quality Agency identifies service risk and ensures those risks are
This focus on identifying serious risk appears to now underlie the Quality
Agency's approach to accreditation and assessment.
The Quality Agency told the committee that in the case of Oakden, due to
a 'culture of cover-up in that facility' it took a significant amount of time
to uncover the extent of service problems:
If I may, I might quote Dr Groves himself on radio here in
Adelaide in April this year. He said that he visited the home for half a day in
June of last year. That is four months after our re-accreditation audit. The
quote was, 'There was nothing to see then.' The fact that he found nothing and
that we did not find it in February of last year doesn't mean that it wasn't
there. It did take Dr Groves, another psychiatrist, a chief psychiatric nurse
and a health researcher who visited the facility for 10 straight weeks to
uncover the rate of abuse going on. There was a culture of cover-up in that
facility. We're determined to take the steps—we're already undertaking the
steps—so that we will be much more alert systemically as well as with the
training and available resources and times to pick that up were that to occur
However, gerontologist Dr Anna Howe submitted that the failure was not
in the information gathered during the audit process, but the subsequent
Quality Agency decision making on what follow up or remediation actions were
Rather than failures to identify poor quality care, the
failures are clearly in decision-making by the Agency that over-rode
recommendations made by assessors who had visited Oakden, had seen poor care,
and had reported on the shortcomings, and done so repeatedly.
The Quality Agency has maintained that, although they held
responsibility for accreditation of the Oakden facility, they should not
shoulder the blame for the failings of that facility due to the misinformation
provided to, and information withheld from, their accreditation staff.
The CEO told the committee that although there were lessons to be learned,
their processes did find problems at Oakden:
We did find noncompliance, and I think it's good to repeat it
for the record. Whilst we think that based on better information we might have
made a different decision 23 months ago—that's in February of 2016—before the
Oakden report ever came out, we were aware of a serious medication error in
late January of last year. We conducted an unannounced assessment contact. We
were very concerned by what we found. We conducted a full review audit—that's a
full audit against all 44 outcomes, not as part of the three-year cycle. We
found  instances of outcomes not met. We reduced their accreditation to six
months. Sanctions were applied by the department at that time. We were meeting
then and were doing, in some instances, daily visits to the homes before Dr
Groves and his colleagues had produced the Oakden report.
So, yes, our system did work but, based on better
information, strength and methodology, it may have been picked the year before....Do
I wish it had worked earlier? Yes. Were there lessons to be learnt? Yes. Did we
publicly acknowledge that and undertake a review? Yes. Did we participate in
all the reviews? We did.
The Quality Agency denied that there was any culture of 'tick and flick'
around assessment processes and noted that there are now processes in place to
rotate accreditation staff through different facilities.
The Quality Agency also told the committee of the requirement for
hospitals to disclose negative findings from any other scrutiny to the health
accreditation process, which is not required in the aged care sector. The
Quality Agency admitted this non-disclosure may have impacted the ability of an
audit process to uncover service concerns:
Had we had access to the information available in the
Clements wing, which is the hospital wing, not the residential aged care wing,
we may have been better focused.
The Quality Agency stated that the principal of open disclosure is
replicated across the world, and the Quality Agency was keen to see that
implemented into aged care audit processes in future.
The Quality Agency further told the committee that it had undertaken a
co-accreditation sample with the Australian Council on Healthcare Standards for
a hospital in Victoria which also provides aged care, and that the Quality
Agency was 'interested in understanding how hospital accreditation and
aged-care accreditation can better work together'.
The CEO of the Quality Agency told the committee of processes it
undertook once the Spriggs family complaint became known:
Clearly, we had information in January of this year of a
medication error at Oakden, at the Makk and McLeay wings of Oakden. We
conducted an unannounced visit and a full review audit. Then, we did find
failure against medication management as an outcome. The performance of a home
can change in 12 months, by the way. The performance of homes can change over
three months. But I was not satisfied that all of what ought to have been found
in February 2016 was found, and that is why I commissioned Nous as a matter of
The Quality Agency told the committee that following the release of the
Oakden report, the Quality Agency appointed Nous Group to provide external
independent advice on any shortcomings in the Quality Agency aged care
The Nous Group report was released in July 2017 and made four key
recommendations, each with short term and long term steps to improve Quality
Broadly, the four key recommendations were:
Use risk-based compliance monitoring.
Strengthen capability of auditors and provide specialist and clinical
Support decision-making functions for accreditation of high-risk
The Quality Agency accepted all recommendations and has begun to
implement them, with a few of the underlying process recommendations referred
to the Carnell Paterson review or the Department of Health for further
The Quality Agency also noted the complementary impact the Carnell Paterson
review recommendation of unannounced audit visits would have to the Nous Group
risk-based monitoring recommendation, telling the committee the 'move to
unannounced visits presents an opportunity for the agency to strengthen our
risk based approach, and we are working quickly to determine how to best
implement this change'.
In February 2018, the Quality Agency described the implemented changes to its
We now ask a series of key questions every time we conduct an
unannounced assessment contact—that's not the re-accreditation audits—so we do
want to understand risk. Where we find areas of concern, we thoroughly and
quickly conduct review audits and we test to see whether there is serious risk
to residents against the standards and if there is any failure against the
As part of the changes to its audit processes, the Quality Agency also
told the committee it had adopted a new computer assisted audit tool which 'makes
findings of compliance and noncompliance far more transparent'
and that recent improvements to risk-based monitoring has resulted in the
Quality Agency being 'better placed to pick up regulatory failure where we find
it; we test in a far more forensic sense the impact upon residents that is in
any way linked to that failure'.
The Quality Agency also described a 'strengthened relationship' with the
Complaints Commissioner and Department of Health as part of the regulatory
system to improve the consistency of accreditation.
Despite this close relationship with the Department of Health, the statutory
nature of the Quality Agency means that the agency is accountable directly to
the Minister and is not subject to any departmental oversight. As outlined by
the Department of Health to the committee:
We don't check the agency. They are accountable for the work
that they do under the legislation that establishes them. They are accountable
through to the minister and therefore the parliament in the same way that the
The Quality Agency also told the committee that, in future, a home with
a history of non-compliance such as Oakden would always remain on the watch
list for monitoring.
The CEO, reaffirming the responsibilities of the Quality Agency, explained to
Any instance of poor care is unacceptable. Where there is an
instance of poor care, and especially a pervasive culture of poor care as there
was at Oakden, every single part of the system clearly has the opportunity to
learn lessons. But do I or do my staff accept responsibility for the abuse or
the neglect that occurred at Oakden? I don't. I don't believe that's a fair
reckoning. I believe, and the law is very clear under the Aged Care Act, that
it's the provider who is responsible. But I'm not a spectator on this, Senator.
I have a key responsibility and, wherever I come across, or my organisation
comes across, not just poor care, we act vigilantly but, if we find that there
was a pattern of misinformation, as was the case in Oakden, I need to know. I
think it's absolutely clear and appropriate that I provide that publicly, if
there are lessons to be learned about risk, especially historic risk, and how
we better determine a long-term risk profile of a home that had historic
noncompliance, serious non-compliance around 10 years ago that that home should
never have fallen off our watchlist.
However, while acknowledging that there are 'clearly learnings for us in
terms of the way that we undertake our work,' the CEO of the Quality Agency
told the committee that 'responsibility for what occurred at Oakden, under the Aged
Care Act 1997, squarely falls with the provider.'
The committee notes that the Quality Agency has provided evidence that a
single visit or accreditation process is sometimes not enough to uncover
abusive treatment of aged care residents, where a facility seeks to hide that treatment.
The committee is greatly concerned for the implications this evidence has on
the adequacy of current processes for ensuing service quality and protecting
aged care residents from abuse, given that many audits and site visits
conducted by various oversight entities are conducted in a single day, as well
as the ability of the Quality Agency to identify where information is being
withheld or altered by providers. The committee is further concerned with
evidence from the Quality Agency that processes required under health
accreditation, which are very useful in uncovering service concerns, are not
required under aged care accreditation processes. These are issues which have
serious implications beyond Oakden, and impact the entire Australian aged care
Although the Quality Agency has undertaken an external review of audit
processes, the committee does not believe that review has addressed these
The committee also wishes to express concerns about the Quality Agency's
repeated refusal to take responsibility for what occurred at Oakden, despite
renewing the facility's accreditation even after repeated non-compliance at
audits over the course of a decade. This continued externalisation of blame
onto the provider and dismissive attitude towards failure does not, in the view
of the committee, show a genuine willingness to learn from the mistakes of the
Carnell Paterson review
As noted previously, in response to the issues experienced at Oakden,
the Minister for Aged Care, the Hon. Ken Wyatt AM, MP, commissioned an
independent review on national aged care quality regulatory processes. The review
report, the Carnell Paterson review, was published in October 2017 and focused
on why 'Commonwealth aged care regulatory processes did not adequately identify
the systemic and longstanding failures of care at the Makk and McLeay wards'.
In releasing the report, the Minister for Aged Care announced that the Carnell
Paterson review recommendation for unannounced visits would be immediately
implemented as the Australian Government continued to consider other details
and recommendations of the review. 
The Carnell Paterson review made a number of disturbing findings in
relation to regulatory oversight of Oakden. In responding to claims that the
increased complexity of service delivery compared to other aged care facilities
caused the poor care outcomes, the Carnell Paterson review found:
[T]here were failures of care for consumers at Oakden that
lay entirely within the scope of the Commonwealth's regulatory system, and were
not caused by the extra layer of state health system regulation and control.
They were issues that any service could experience.
The Carnell Paterson review found three issues with accreditation that
need to be addressed which, in summary, are:
Some expected outcomes under the standards are inappropriate,
particularly for leadership and restrictive practice.
Accreditation needs to look deeply into a service, by achieving more
evenness in the examination of services and skills training of surveyors.
Services may prepare for accreditation cycles instead of focusing on
continuous quality care.
The Carnell Paterson review made six key recommendations:
Establish an independent Aged Care Quality and Safety Commission
to centralise accreditation, compliance and complaints handling (with an
additional four recommendations relating to this new body).
Enact a serious incident response scheme (SIRS) for aged care.
Limit the use of restrictive practices.
Implement unannounced accreditation visits.
Strengthen assessment processes.
Enhance powers of the complaints commissioner.
As outlined above, the Minister for Aged Care has moved to implement
unannounced accreditation visits, while the remainder of the Carnell Paterson
review findings and recommendations are under review by the Australian
The Department of Health have indicated that responses to further
recommendations from the Carnell Paterson review will likely be included in the
2018–19 Federal Budget.
The recommendations of the Carnell Paterson review go well beyond issues
occurring at Oakden, and call for a complete overhaul of the quality oversight
and regulation framework, as well as the complaints investigation systems for
the aged care sector nationally.
The committee agrees with the findings of that review, as the evidence
to this inquiry received to date makes a compelling argument that the current
system is out of date and is failing its duty of care to vulnerable older
Further the committee is not confident that there is not abuse elsewhere
that the current compliance system has not identified.
Australian Health Practitioners
The Australian Health Practitioner Regulation Agency (AHPRA) regulates
14 health professions, including all staff responsible for clinical assessment
and medical care within an aged care context. They include doctors, registered
and enrolled nurses, as well as physiotherapists, occupational therapists and
certain other allied health staff. The Complaints Commissioner does not have
jurisdiction in relation to the actions of individual registered health
practitioners, and refers such complaints to AHPRA for investigation.
As at 8 August 2017, a total of 34 registered health practitioner staff
were referred to AHPRA for investigation in relation to Oakden.
To date, 13 practitioners have been issued with a caution or undertakings
(which can range from requirements for education or professional monitoring or
mentoring), one practitioner has been referred to a tribunal and subsequently
disqualified from practice, and there are 12 open notifications under
Concerns with response
Submitters and witnesses who discussed the effectiveness of government
responses to quality of care issues at Oakden, were largely concerned that
Oakden was not an isolated case and highlighted systemic problems with the
overall aged care quality and oversight systems nationally.
Evidence presented to the committee has suggested that there is no trend of
aged care facilities being sanctioned or otherwise investigated in SA more than
any other state or territory.
Professor Joseph Ibrahim of Monash University told the committee of his
My greatest concern, listening to the evidence today, is that
you are focusing on a single episode rather than on the system as a whole. The
research we've done indicates that bad things happen every year in every state
that are potentially preventable. So what we have is a systems-wide issue in
the same way that we had with patient safety in hospitals back in the nineties
which we have tried to address.
The Carnell Paterson review found that a view was regularly expressed
that the Oakden case should be considered rare because the structure of Oakden
was atypically complex, and that the residential aged care system as a whole is
generally of high care. The Carnell Paterson review argued that both of these
views 'risk understating the significance of the systemic issues that Oakden
The Carnell Paterson review went further and found:
[W]e know from Dr Groves' investigations at Oakden that the
quality of care there was not accurately represented in the Agency's
evaluations. If this is true at Oakden, it could well be the case elsewhere, a
possibility raised with this Review by stakeholders. Accordingly, it is not
possible to rely solely on the level of reported compliance with the
Accreditation Standards as a robust indicator of quality in the residential
The Australian Medical Association expressed a similar view and
submitted that Oakden should be viewed in context of the broader aged care
Australia's aged care system is failing older people. The
Oakden Report has shed light on a wide range of issues facing aged care. Our
members are of the view that the occurrences at Oakden Older Mental Health
Service (Oakden) were not isolated incidents, as they believe similar issues
are seen throughout the entire aged care system.
Chapter 4 will discuss the broader concerns raised by witnesses and
submitters to this inquiry, as well as detail some recent and ongoing actions
being taken in relation to the regulation of the national aged care sector.
It is clear from the evidence presented to this inquiry and from the
reports of the two key external reviews into Oakden, that once action to
address quality of care issues at Oakden was finally taken by the responsible
government entities, it was extensive and effective. What is of deep concern to
the committee is the length of time it took for the SA Government and
Australian Government to respond to the concerns of residents, their families
and whistleblower staff who had been raising issues for many years to no effect.
Many subsequent instances of abuse and neglect occurred as a direct result of those
with the oversight responsibility not acting earlier.
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