The State Government has received the report from the independent reviewers examining the mental health treatment of alleged murderer Shaun Michael Dunk and will adopt all recommendations.
The Government is today releasing findings and recommendations of the review, at the first opportunity after last night meeting with the victims’ families to discuss the findings and recommendations with them.
All six recommendations, which each have several components, have been accepted and will be implemented.
The Government immediately ordered an independent review following the horrific stabbing attack of two women at a Plympton real estate agency in December.
The Office of the Chief Psychiatrist commissioned the review which examined the circumstances around the alleged murderer’s treatment for mental health. He had been treated by the Royal Adelaide Hospital (RAH) and Urgent Mental Health Care Centre (UMHCC) prior to the attack.
The independent review was led by an independent interstate expert, Dr Sophie Davison who is Chief Medical Officer at the Western Australian Mental Health Commission, working with Associate Professor Sandra Keppich-Arnold, Director of Operations in Mental and Addiction Health at Alfred Health in Victoria.
The summary report, findings and recommendations have been made publicly available today. The full report is unable to be released due to the ongoing criminal Supreme Court prosecution.
The review found:
“…there was no evidence of any individual clinician’s assessment, treatment or decisions falling below an acceptable standard or not being justifiable at that point of time with the information available to them”.
However, more broadly it did identify systemic issues including the RAH emergency department model of care not designed or resourced for effective mental health treatment, the use of security guards to monitor mentally unwell patients, prolonged waits in the RAH emergency department for mental health beds, and information sharing between the UMHCC and the RAH.
The Government is adopting all recommendations including:
- Reviewing mental health staffing and responsibilities in the RAH ED
- Reviewing the role of security guards in the RAH ED in the context that continuous observation is not a custodial activity
- Undertaking an audit of the management of patients presenting to the RAH ED under the influence of illicit substances
- Establishing a service level agreement between the RAH and Urgent Mental Health Care Centre (UMHCC) to confirm ways of working
- Developing a shared process between the RAH and UMHCC to flag frequent attenders
- Enabling staff at UMHCC to access SA Health Clinical Information systems
- Developing a mechanism to record UMHCC attendances and reason for presentation on relevant SA Health clinical information systems to provide a clear centralised record of consumers’ contact with all mental health services
- CALHN undertaking a review of existing risk assessment and safety planning policy
- CALHN developing a training package for staff to ensure capability in risk assessment, formulation and safety planning
- Reviewing current practices to prioritise mental health review of patients transferred to non-mental health wards whilst under the Mental Health Act
Chief Psychiatrist Dr John Brayley and SA Health Chief Executive Dr Robyn Lawrence have been tasked with overseeing the implementation of the recommendations.
While the independent reviewers did not make recommendations to change the Mental Health Act, the Government is considering any changes that can be made. In addition, more broadly the Government is also considering further reforms in the justice system and further actions to help prevent violence against women.
The Government is investing significantly to expand mental health services in South Australia, including opening more than 130 new mental health beds across the state, including new mental health units at the Queen Elizabeth, Noarlunga, Modbury and Mount Barker hospitals as well as expanded community mental health care.
The report summary including findings and recommendations can be found here.
Quotes
Attributable to Chris Picton
This horrific case shocked and distressed all of us and our thoughts remain with the family of Julie Seed as well as Susan Scardigno and her loved ones.
Alongside the police investigation, we immediately ordered an independent review into the circumstances surrounding the alleged perpetrator’s treatment for mental health.
Upon receiving this report, we have given the first opportunity to the families to discuss the findings and recommendations, and are now immediately releasing them publicly and to our clinical teams.
We are adopting and will implement all recommendations from the independent reviewers.
We want to do absolutely everything we can to prevent terrible violence in our communities, and to keep people safe.
Attributable to Chief Psychiatrist Dr John Brayley
The system findings and recommendations released today will improve assessment, observation and communication.
Both the agreed system changes and future law changes aim to improve the care for individuals, enhance community safety and support staff.
There have been a number of incidents around Australia that have distressed our entire community. People with lived experience of mental illness have also experienced this distress and in addition experienced unfair stigma. Our frontline staff feel the pressure to keep patients and the community safe. The next phase of implementing service changes and consulting on new laws will be done to maximise their effectiveness but also to ensure they support frontline staff in their work.
