Chief psychiatrist John Brayley told InDaily he needed additional legal back-up in his inquiry into mental health services in the Southern Adelaide Local Health Network – an investigation requested by former Independent Commissioner Against Corruption Bruce Lander before he left the role this year.

Brayley revealed the legal complexities of the investigation, which has its roots in an inquiry he began more than two years ago, had led him to employ Sam McGrath in September 2019.

Two years earlier, McGrath was the principal solicitor assisting the ICAC in his maladministration inquiry into the disastrous Oakden Older Persons Mental Health Service. That inquiry produced a devastating report which described abuse of patients and maladministration at the understaffed, now closed, facility that cared for elderly patients with dementia.

“For an investigation such as this, we obviously need clinical expertise, but (also) legal expertise,” he said. “We needed to obtain this independently and separately. So we approached an external lawyer…. and one of the reasons for approaching him was his experience previously for ICAC.”

The Chief Psychiatrist completed a preliminary report into selected SALHN mental health services earlier this year and is now working on a final report to ICAC, with conclusions about patient care and quality of management.

That preliminary investigation, ordered by Lander in January 2019, found a series of problems with three services, leading him to gazette formal conditions on their management, including direct oversight by him of some aspects of clinical management, including the discharge of patients.

Brayley’s initial investigation began before Lander got involved after clinicians, families of patients, unions and the Community Visitor raised numerous concerns about mental health services in the outer southern area, including understaffing, dysfunctional management, and “discharge pressure”, which some doctors and family members believe may have led to the deaths of mental health patients.

In an interview with InDaily this month, Brayley revealed that his investigation was looking into some patient deaths but he would not provide any comment, citing the secrecy provisions of the ICAC Act.

However, he did say that some details from his investigation had been provided to the Coroner.

Brayley first began an investigation into the SALHN mental health services in the outer southern suburbs in 2018, but he won’t put a timeline on when his final report will be completed.

The problems behind the investigation

Concerns about the management of public mental health services based at Noarlunga have been raised for years.

In 2018, InDaily reported deep concerns among clinicians about the functioning of the services, including doctors offering a vote of no confidence in SALHN’s clinical oversight of mental health services in the outer south. That same year, then Community Visitor Maurice Corcoran raised concerns about the services, including the death of a patient allegedly discharged too early.

An independent review of the Noarlunga-based services, leaked to InDaily in 2018, detailed a “fragmented” service, which had suffered from ongoing staffing problems, including poor planning and patchy staff coverage.

“The lack of planning for staffing has also resulted in uneven workloads with some days having a full complement of psychiatrists on-site and other days virtually no psychiatrists available,” said the review, conducted by health management consultant Lee Gruner.

The review found psychiatrists have felt “devalued and disrespected”, “aggrieved and angry”, with their grievances stemming from a decision “some years” ago to replace a site-specific clinical director with an overarching manager based at Flinders Medical Centre.

In July this year, with his investigation ongoing, Brayley intervened, using powers that he has increasingly exercised following the Oakden debacle (Brayley wasn’t Chief Psychiatrist when the Oakden scandal occurred).

He used his powers under the Mental Health Act 2009 to impose temporary conditions on three SALHN mental health services: the Adaire Clinic, Noarlunga Emergency Department, and Southern Intermediate Care Centre.

He said at the time the conditions would be in place until his investigation was finalised and would ensure he has direct oversight of care plans and, in the case of Southern Intermediate Care Centre, would limit admissions unless approved by a senior manager.

Brayley said his concerns related to “systems and processes” including referral and handover of patients and the “capacity and capability of community teams to accept referrals of acutely unwell consumers”.

“I also considered that there was a need for additional oversight of the delivery of acute care in the community and in the Emergency Department when consumers are discharged home to community care,” he said.

“In a number of cases I was concerned that telephone reviews were relied on when face-to-face contact would have been preferable.

“I observed that a specific unit, the Southern Intermediate Care Centre (at Noarlunga Hospital), operates on what I considered to be an outdated care model that does not address the acuity of the consumer group it admits.”

Those conditions remain in place.

Oakden’s shadow

In the wake of the Oakden disaster, this is the new normal: the Chief Psychiatrist more aggressively oversees public mental health facilities, imposing conditions on their operations, and making unannounced site inspections and investigations.

However, this doesn’t mean public scrutiny is necessarily higher.

Unlike Oakden, the SALHN mental health issues have been little reported beyond InDaily – and there has been little information provided publicly by SA Health and Brayley himself.

In an interview with InDaily this month, Brayley refused to answer a raft of questions due to the secrecy provisions of the ICAC Act.

Here’s what he was prepared to say.

Have standards improved since Brayley’s intervention?

Brayley said he had been “pleased with the proactive response of SALHN” since his gazettal conditions were imposed in July.

However, he would not say directly whether clinical standards had improved and revealed that one of the services was still operating under an “outdated” model of care.

“We can be reassured with the clinical standards,” he said.

“We have had concerns in the past that we need to make a final conclusion about in the investigation… The gazettal conditions provide this extra check and balance because senior staff are reviewing whether the service can take on people with acute needs, but it is also a way of checking that care is delivered.

“I have been reassured by what I”ve been seeing in these reports and the discussions with staff and the operations of these conditions.”

He said the model of care for the community mental health team was no longer outdated, but the Southern Intermediate Care Centre at Noarlunga – which supports mental health patients after discharge from hospital – did not yet have an updated model of care.

“There is still work being done on the intermediate care centre, and that still has its old model of care in place… The critical immediate issue is that there is a check to make sure that the level of acuity of people being admitted into that centre matches what the staffing and the design of the centre can provide, and that check is occurring.”

Brayley said his investigation was into “systems and processes” and repeatedly emphasised that he had faith in the “dedication and skill” of staff in the services.

“The impression that I have gained from my investigation to date is that staff and clinicians across the service in community teams and community residential services, and in the inpatient hospital setting, are providing care in the vast majority of cases with care, diligence and professionalism, albeit under pressure.”

Are the services still under pressure to discharge patients?

The death of a SALHN mental health patient in 2018 was detailed by then Principal Community Visitor Maurice Corcoran in 2018.

The tragedy highlighted Corcoran’s concerns about increasing pressure on mental health services to discharge patients, in order to reduce backlogs in emergency departments. He said he was concerned about “bed allocation being based on bed flow priority, not clinical need”.

This is an issue raised by clinical staff in SALHN mental health, with Lee Gruner’s report documenting concerns that, on some shifts, there were no psychiatrists present to oversee care.

The issue of discharge was mentioned as an issue in Brayley’s preliminary report, but he told InDaily he was confident the matter was being addressed with a redesign of services.

He was also overseeing the discharge of patients as part of gazettal requirements.

“I can say that in the coming months, it will be possible to lift most of the gazettal conditions if this initial positive impression continues,” he said.

When asked whether there had been inappropriate discharges in the past, he said. “Some of that question relates to the investigation and I can’t respond to that because of the ICAC requirement and the preliminary nature of the report… Staffing is also part of the investigation (staffing levels).”

Management problems

Brayley would not comment on the quality of management of the service at any point in the past, nor whether he believed there was a cultural issue with SALHN’s management of the services.

“To talk about the management of the service at any time would be pre-empting the investigation and also could create a problem with ICAC Act obligations,” he said.

“We have had high levels of engagement in our investigation and then the implementation of gazettal conditions.”

Impact on patients

Brayley says his investigation of the services has included in-depth case studies of patient care, including some patients who died.

InDaily asked what he would say to people who had lost family members or loved ones because of what they believe to be deficiencies in their treatment by SALHN facilities.

After a long pause, he said: “Suicide prevention is perhaps the most critical quality outcome for a mental health service and much can be said about that topic, what needs to be done, and the just response for people who are bereaved by suicide.”

“I cannot answer this question specifically because it involves individual case reviews, with in-depth reviews, and the final conclusions are yet to be made.”

He said discussion of specific cases would be part of the final report to ICAC and that “specific people and the work that … we have done has also been shared with the coroner”.

“Obviously in-depth reports have been completed.”

What’s next

Brayley says he cannot put a timeline on the completion of his final report for ICAC.

He says that when it is completed, he may produce a summary which removes people’s identities because the preliminary report contains “quite detailed and identifiable material”.

“There has been significant interest in this investigation, so I would expect to be able to provide something by way of (a) deidentified summary of what has been looked at,” he said.

He also promised to contact families of patients whose cases are discussed in the report.