???A damning inquiry has exposed the "traumatising" use of seclusion and restraint in NSW mental health units and emergency department 'safe rooms', describing entrenched discrimination, stigma and prison-like punishment many patients are subject to.
The independent review into restrictive practices in NSW mental health settings was released on Monday after months of public forums, submissions and inspections of psychiatric units and EDs.
Patients and their families described services "that traumatise and show a lack of compassion and humanity" including a culture that promoted strip-searching and other punitive methods, according to the report.
The review led by NSW chief psychiatrist Dr Murray Wright detailed instances of patients being "trapped, claustrophobic and agitated" in seclusion rooms "built like prisons" with no access to bathrooms or fresh air.
Many patients "reported feeling dehumanised and stripped of their sense of autonomy, agency, dignity and human rights," the report read.
"Some consumers and carers reported that seclusion and restraint were used as a threat or a punishment; as a means of enforcing compliance and obedience"
The exhaustive and harrowing report was dedicated to Miriam Merten, whose disturbing treatment in seclusion captured on CCTV footage while she was a patient at Lismore Base Hospital sparked outrage and provided the catalyst for the report.
The footage showed Ms Merten disoriented, naked and covered in faeces in the hours before she died of traumatic hypoxic brain injury on June 3, 2014, caused by numerous falls and beating her head against hard surfaces in a seclusion room.
There were close to 3700 episodes of seclusion and restraint in NSW in 2016-17. Roughly 2200 people were secluded for an average of five-and-a-half hours. These figures do not include those who were secluded in a hospital emergency department.
The Wright review detailed the traumatic overuse of the so-called 'safe rooms' in EDs and a culture that was "overtly stigmatising and discriminatory towards mental health consumers and, in some instances, towards mental health staff as well.
The review found this discriminatory and stigmatising behaviour at all levels of the workforce, and staff with insufficient skills and basic mental health knowledge working with patients.
Reviewers found "no convincing examples" of collaborative leadership in mental health units, and described confusing policies, inconsistent approaches to patient safety, no reliable monitoring system of seclusion and restraint in emergency departments.
There was no routine on-site after-hours supervision in several mental health units, inconsistent individualised care planning and access to data on seclusion and restraint, according to the report that revealed underlying factors that had implications beyond the mental health system.
State Health Minister Brad Hazzard and Mental Health Minister Tanya Davies announced the government would implement all 19 of the report's recommendations including minimum training standards for staff and improving transparency in seclusion and restraint reporting.
The government would also immediately invest $20 million to help hospital managers improve their therapeutic environments, and launch a further review of ED safe rooms.
Mr Hazzard said the message from the review was loud and clear: "Seclusion and restraint of mental health patients should be a last resort."
He said the government would need to work with local health districts to bring about change in practices and procedure.
Ms Davies said seclusion and restraint incidents have been gradually declining since 2011, and implementing the report's recommendations would accelerate the downward trend.
"We must now ensure every member of our dedicated workforce is confident with and trained in these care models, and it is embedded in all aspects of leadership," she said
Acting NSW Mental Health Commissioner Karen Burns said the review shone a light on the outdated and harmful practices and did not shy away from the trauma they inflicted on patients.
Ms Burns said the commission endorsed all 19 recommendations and would monitor the NSW government's moves to implement them.
"The community needs to have absolute trust that when they or a loved one needs care for an acute mental health issue, they will be safe and respected, and not re-traumatised or harmed in any way," she said.
National Mental Health Commissioner Professor Ian Hickie commended the "honest and straight-forward" report and moves to improve transparency in reporting seclusion and restraint data.
Professor Hickie clinical staff would need to be the drivers of change aimed at eliminating seclusion and restraint.
"Unless there is clinical leadership, there will be no cultural change," he said.
"It's up to the willingness of the medical workforce to take responsibility for what happens next."
Professor Hickie said transparent reporting would ensure best practice was recognised, and he urged the government to publish publicly available seclusion and restraint data for individual hospitals every quarter.
The review's recommendations included:
- Minimum standards and skill requirements for all staff in mental health
- 24-hour on-site supervision from accountable managers
- An immediate review of the design of safe rooms
- Adopting an integrated leadership development framework
- A single, simplified principles-based policy towards eliminating seclusion and restraint
- Increasing, developing and professionalising the peer workforce
- Engaging with consumers and families in assessing and planning care
- Co-designing care with consumers and families
- Improve transparency, reporting and publishing seclusion and restraint data including EDs
- A multidisciplinary team on an extended hours basis at all mental health units
The NSW Ministry of Health will deliver a plan in March 2018 outlining how the recommendations will be implemented.