Review of Roy Fagan Centre Older Persons Mental Health Services
Chapter 1
Introduction
In late December 2020, Mr Dale Webster, Deputy Secretary, Community Mental Health and Wellbeing (CMHW) Department of Health, contacted me in my role as the Chief Psychiatrist of Tasmania and requested that I undertake a Review of the Roy Fagan Centre (RFC).
He also requested that I provide advice to the Secretary of the Department of Health about an appropriate senior nurse, with experience in both mental health and general nursing, who was based outside Tasmania, and who had the appropriate skills to conduct a review of the standards of patient care.
Subsequently, Ms Del Thomson was also appointed as an additional independent member of an Advisory Panel established under the Tasmanian Health Services Act 2018 to conduct the Review of RFC.
The Review commenced on 11 January 2021, with a requirement to provide an initial report by 15 March 2021.
Comprehensively reviewing the standard of patient care in a service of this size, for a period that encompassed the previous 12 months, is challenging and required the assistance of several people, in particular the senior staff of the RFC. We are indebted to them for their prompt and helpful assistance; no request was considered too difficult and without their dedication to meeting our requests the report could not have been finished on time.
I am also grateful to all of the staff of the RFC who made themselves readily available for interviews, notwithstanding many had just completed 12 hour night shifts, now worked in different services, or were on extended leave, but were still keen to be interviewed and provide valuable insights.
This report is arranged in sections that cover the background to the review and its processes; then 3
Chapters each of which is devoted to addressing one of the Terms of Reference of the Review.
These Chapters include: An overview of the patient care of Mr A, with findings; a summary of standard of patient care of other residents in RFC over the previous 12 months, with findings; and the recent history of and planning of Older Persons Mental Health Services (OPMHS) in Tasmania, with findings.
The report is based on numerous staff interviews, some written submissions, a review of a representative selected sample of clinical files, an examination of selected policies, procedures and protocols, interviews with external Government bodies that are regularly involved with the RFC, external providers, an externally provided specialist opinion, and the observations of the members of the Review when onsite and as a formal part of the Review.
Great care has been taken to ensure all findings within the report are based directly on this material and the source material is available to Statewide Mental Health Services (SMHS) the organisation within the Tasmania Health Service that has overall responsibility for the standard of patient care provided by OPMHS and the RFC, for them to verify the observations and findings that have been made.
To ensure the anonymity of all people who provided information to the Review team, the report does not contain the details of who made which statements, or which documents, including residents’ clinical files or other correspondence that has been relied upon, unless prior permission has been provided for this to be identified in the report.
The report makes 13 main findings and 6 recommendations. The main findings are summarised as follows:
1. The standard of care provided to Mr A in the 24 hours before Christmas day 2020 was well below an acceptable level.
2. The standard of care provided to Mr A throughout the rest of Mr A’s admission was at a satisfactory level.
3. The overall level of care provided to resident of Roy Fagan Centre was satisfactory
4. The Clinical Leadership of RFC acted immediately and made changes to processes and procedures, that should have been made.
5. The RFC workforce is well placed to embrace change and improvement.
6. There is no contemporary model of care.
7. There is an insufficient number and type of nursing staff for the variety and complexity of patient need.
8. There is an overall significant deficit in Allied Health Staff in the Roy Fagan Centre. This has a major significant negative impact of the level of care provided in these units.
9. The number and training of direct care staff should be reviewed once an overall appropriate level of professional and vocationally trained staff is achieved.
10. There has been inadequate attention paid to planning or prioritisation of OPMHS throughout
Tasmania.
11. There has been a lack of overall investment in OPMHS, despite this program expected to see the greatest growth in demand given the ageing population.
12. The OPMHS has not been developed to include the full range of service elements.
13. The Roy Fagan Centre facility is both out of date and inadequate for some of the people who are admitted to the facility.
The summarised recommendations are as follows:
1. OPMHS should be a statewide program within SMHS and have its own dedicated leadership.
2. OPMHS should develop a comprehensive system of Clinical Governance, with dedicated resources to support this function, in line with the Tasmanian Quality Governance Framework.
3. OPMHS should be funded to deliver the full range of service elements found within a contemporary statewide OPMHS.
4. The RFC should undertake a project over the next 12 months to develop a model of care based on a new level of resourcing adequate to undertake the roles it will need to deliver in the next 10 years.
5. The Community OPMHS should develop a model of care that meets the needs of the Tasmanian community based on similar programs elsewhere in Australia.
6. OPMHS should develop a project as part of the broader Tasmanian Mental Health reforms that ensures they are able to take advantage of processes that will assist them in attracting a suitable workforce.
Read the full report.
Media release – Jeremy Rockliff, Minister for Mental Health and Wellbeing, 13 July 2021
Roy Fagan Centre Investigation
An independent review established to examine the standard of patient care at the Roy Fagan Centre has made six recommendations, all of which the Tasmanian Government accepts.
The review followed an incident involving the care of a patient in December 2020.
It found that the standard of care provided in the 24 hours prior to Christmas Day 2020 did not meet our standards or expectations with a culmination of factors, that when combined, led to this incident occurring.
I stress that what occurred is not a reflection on any of the hard-working staff working at the Roy Fagan Centre.
The Tasmanian Government will do everything possible to ensure we never see a repeat of this type of incident, and we will ensure the recommendations are implemented as a priority.
On behalf of the Tasmanian Government, I unreservedly apologise to the patient’s family.
I would also like to thank them for their assistance throughout this review and their efforts to help improve patient care, treatment, and outcomes.
This process has no doubt been extremely distressing for them, and I would like to acknowledge the courage and commitment they have demonstrated throughout.
The Tasmanian Government will now develop an implementation plan for the review recommendations as a priority, and I am confident this will significantly improve the level of care and treatment provided to older Tasmanians, and better meet the needs and expectations of the Tasmanian community.
The full report can be found on the Department of Health Website.
Media release – Australian Medical Association Tasmania, 13 July 2021
ROY FAGAN CENTRE INQUIRY FINDINGS
AMA Tasmania Vice President Dr John Saul said today that the AMA welcomed the long-overdue release of the report into a patient’s care at the Roy Fagan Centre.
“It is important that lessons are learnt by everyone at all levels of government from the circumstances surrounding the event that led to this report.
“The report makes it clear that there is a need for more nursing and allied health staff to keep the quality of care at the level every Tasmanian should expect for themselves or their family requiring the care of the Roy Fagan Centre.
“AMA Tasmania supports the six recommendations in the report, which offer a constructive way forward to strengthen services for older persons.
“We encourage the government to work with all staff, but particularly the Executive Clinical team, to implement the report’s recommendations and further improve the services for older people.
“What is clear is that additional resources to employ more staff with specialist skills in caring for older people with mental health issues are required to meet increasing demand for these services and ensure quality care can be provided at all times.”
Dr Saul said retaining existing doctors and nurses and recruiting more doctors and nurses must be at the top of the government’s agenda.
“We know patients in the care of the Roy Fagan Centre can have challenging care needs.
“Nursing people with severe dementia symptoms, who may be violent or resistant to personal care, is very different from nursing someone recovering from surgery.”
“The staff at Roy Fagan are dedicated to their patients and work tirelessly to deliver the best care they can in the circumstances.
“However, they need more nurses trained in geriatric mental health and specialist medical practitioners.
“The centre has had trouble recruiting to Registered Nursing positions and has been forced to rely on too many casual staff.
“To attract people into dementia care, nurses need to be paid more than their counterparts in other nursing disciplines.
“And to retain and attract doctors with specialist skills in older persons mental health, we need to ensure that our wages are competitive with other jurisdictions.”
Media release – Dr Bastian Seidel MLC, Shadow Health, Mental Health and Wellbeing Minister, 14 July 2021
Accountability and action – not just more talk – needed after Roy Fagan tragedy
After stalling a crucial report on the unacceptable tragedy at Hobart’s Roy Fagan Centre and accepting responsibility but not accountability, Health Minister Jeremy Rockliff needs to tell Tasmanians today what he will do to fix the situation.
Shadow Minister for Health, Mental Health and Wellbeing Dr Bastian Seidel said Mr Rockliff had failed patients and staff by doing nothing to lift the Gutwein Government’s unacceptable level of care despite having knowledge of chronic staff shortages for at least seven months.
“Jeremy Rockliff has been the Minister responsible for care at Roy Fagan for the past two years, not just the past two days,” Dr Seidel said.
“The report on this heartbreaking situation involving a 78-year-old patient who was found infested with maggots has been available to Mr Rockliff since March – before the state election – but he chose to keep it hidden.
“He has accepted responsibility but at no stage has he provided a timeline for when he intends to adopt this report’s recommendations and at no time has he given any financial commitment to fix the situation.
“This is supposed to be Tasmania’s top mental health facility where some of our most vulnerable are supposed to receive the best care but staff are simply unable to do that because the Liberal Government will not provide them with even adequate resources.
“There has been plenty of time for this Minister to act. There has been plenty of time for him to bring staffing levels up to scratch so families can be confident their relatives – who in most cases are helpless – are receiving proper care.
“He has failed and Mr Rockliff needs to very specifically tell Tasmanians where is his accountability?
“Labor went to the election with a comprehensive plan to establish a second campus at the former Hobart Repatriation Hospital site which would include a state-of-the-art mental health facility – something that is desperately required in Tasmania.
“Mr Rockliff needs to immediately provide details of what he plans to do.”
