Chief Psychiatrist's annual report 2008-09 - Department of Health

Chief Psychiatrist’s annual report 2008-09

4 Clinical review of area mental health services 1997-2004

Chief Psychiatrist’s annual report 2008–09

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March 2010 (DHSJK310)

February 2010
The Honourable Lisa Neville MP
Minister for Mental Health
50 Lonsdale Street
Melbourne Vic 3001
Dear Minister,
I am pleased to enclose the Chief Psychiatrist’s sixth published annual report, covering the
2008-2009 financial year.
The report describes the activities of the Office of the Chief Psychiatrist in fulfilment of my
responsibilities under the Mental Health Act 1986 in respect to the treatment and care of people
with a mental illness in Victoria. I trust the report continues to inform the public, consumers, carers
and others about the role and function of the Chief Psychiatrist and work undertaken by my office
to monitor and improve the quality of treatment and care in public mental health services, and to
protect the human rights of the mentally ill.
Yours sincerely,
Dr Ruth Vine
Chief Psychiatrist
MB BS, LLB, FRANZCP

Foreword
Two important reports released in the 2008–09 financial year will influence mental health policy
and service delivery over the coming years. The first was the development of a new whole-ofgovernment
reform strategy for mental health, which culminated, in March 2009, in the release
of Because mental health matters. Victorian Mental Health Reform Strategy 2009–2019.
The second was the review of the Mental Health Act 1986.
Both initiatives were large-scale undertakings, underpinned by a broadly-based consultative
process. Each is expected to contribute, over time, to the further development of a mental health
service system that is increasingly responsive to the diverse needs of consumers and their carers
and families.
The Office of the Chief Psychiatrist actively contributed to these initiatives and will play an equally
important role in helping to monitor and shape the impact of structural change upon clinical
practice in mental health services; and in assisting with the implementation of the new legislation
once it is enacted and promulgated.
For the Office of the Chief Psychiatrist, 2008–09 was also a year of transition. Adjunct Professor
Kuruvilla George held the position of Chief Psychiatrist on a part-time basis until May 2009, when
Dr Ruth Vine was appointed to the position. Professor George was assisted in the course of the year
by Professor Mark Oakley-Browne, Associate Professor Ravi Bhat, Dr Steve Macfarlane and Dr David
Huppert as deputy chief psychiatrists. A new position of Deputy Chief Psychiatrist, Child and Youth
Mental Health, was created in March 2009.
I commend Professor Kuruvilla George upon his accomplishments as Chief Psychiatrist from
September 2007 to May 2009 and I look forward to continuing to work with him in the role of
Deputy Chief Psychiatrist, Aged Persons Mental Health. The appointment of Dr Sandra Radovini
as the inaugural Deputy Chief Psychiatrist for Child and Youth Mental Health places the office in
a good position to guide the development of a new service model for child and youth mental health
services, which is a major objective of the Mental Health Reform Strategy.
Achievements over the past year include:
• completion of the Creating Safety project, which aims to foster the creation of safe and
therapeutic inpatient environments, in which the use of seclusion and restraint can be
significantly reduced
• the development and publication of a new Electroconvulsive therapy manual
• contribution to the development of a mental health response to assist persons affected by the
February 2009 Victorian bushfires
• the development and publication of a new Chief Psychiatrist guideline on restricted involuntary
treatment orders and restricted community treatment orders
• completion of a memorandum of understanding between the Chief Psychiatrist and the Health
Services Commissioner regarding the handling of complaints
• collaboration with other stakeholders on a range of clinical and strategic initiatives, including the
development of a new triage tool and reviews of the statewide child inpatient unit and adolescent
inpatient units
• participation in cross-border consultations with stakeholders and membership of a steering group
developing guidelines for cross-border arrangements.

A large segment of the work of the office is of a routine nature. This includes the receipt
and monitoring of statutory reports pertaining to restraint, seclusion, reportable deaths and
electroconvulsive therapy; responding to telephone and written complaints and enquiries; providing
high-level clinical advice to the sector and to the department; liaising with service providers,
particularly in coordinating services for consumers with complex and high-risk presentations; and
undertaking defined responsibilities for mentally ill offenders.
With the Office of the Chief Psychiatrist now entering a new period of stability, I look forward to
further enhancing clinical practice in Victoria’s mental health services through a range of strategic
activities including a revamped program of clinical reviews, the ongoing development of clinical
guidelines and engagement with the sector. The Office will be actively involved in policy and
service planning within the Mental Health, Drugs and Regions Division, and will engage with service
providers, consumers and carers and other key stakeholders to support the provision of accessible,
safe, high-quality mental health services.
Dr Ruth Vine
Chief Psychiatrist

Contents
1 The role of the Chief Psychiatrist 1
2 Statutory reports for 2008–09 3
3 Contacts, complaints and enquiries 19
4 Investigations 25
5 Working with the sector 26
6 Improving service quality 31
7 Working with the department and other stakeholders 34
8 Forensic mental health 37
Appendix: Membership of the Quality Assurance Committee 39

Chief Psychiatrist’s annual report 2008–09 1
1 The role of the Chief Psychiatrist
Section 105 of the Mental Health Act 1986 (‘the Act’) establishes the appointment of a Chief
Psychiatrist who is ‘… responsible for the medical care and welfare of persons receiving treatment
or care for a mental illness’.
The Chief Psychiatrist is appointed by the Secretary of the Department of Health and is subject to the
Secretary’s general direction and control. The Office of the Chief Psychiatrist sits within the Mental
Health, Drugs and Regions Division of the department. The Chief Psychiatrist is supported by a small
team of departmental staff with expertise in the mental health field who are appointed as authorised
officers to assist in carrying out the functions of the office. Authorised officers can make extensive
enquiries about the admission, detention, care and treatment of persons with a mental illness.
The Chief Psychiatrist has a range of powers, duties and functions conferred by the Act.
• The power of delegation. The Chief Psychiatrist can delegate any power, duty or function (other
than the power of delegation) to a qualified psychiatrist appointed under section 95 of the Act or
to an authorised officer appointed under section 106 of the Act to assist in the performance of
statutory functions.
• The power of inspection and enquiry. If concerned about the medical care or welfare of a person,
the Chief Psychiatrist may visit a psychiatric service, inspect the premises, see any person
receiving treatment and care, inspect and take copies of any documents, and make enquiries
relating to the admission, detention, care, treatment and control of people with a mental disorder
in or from a psychiatric service.
• The power of direction. Following investigation, the Chief Psychiatrist may direct a psychiatric
service to provide or discontinue treatment, and admit an involuntary patient. The Chief
Psychiatrist may also direct the transfer of patients from one mental health service to another.
• The power to discharge involuntary patients from certain orders.
• The power to order that security patients be discharged and returned to prison, and to consider
applications for special leave to allow security patients access to the community. The Chief
Psychiatrist must be consulted on applications for leave of absence for security patients.
• The power to license premises in the public and private sectors to perform electroconvulsive
therapy (ECT).
• The power to receive statutory reports on the performance of ECT in licensed premises, seclusion
and mechanical restraint in approved mental health services, the death of persons ‘held in care’
or receiving treatment for a mental illness, and the annual medical examination of those treated
as involuntary patients for a period of 12 months or more.
Some of the activities undertaken by the office to fulfil these responsibilities include:
• receiving and reviewing statutory reports relating to seclusion, mechanical restraint,
electroconvulsive therapy, annual examinations and reportable deaths
• responding to enquiries from service providers, service users and the public
• investigating complaints from consumers, carers, members of the public and others
• providing advice to consumers, carers, mental health practitioners and services
• mediating between and liaising with mental health services to achieve improved individual
and service system outcomes, particularly for consumers with complex presentations

2 Chief Psychiatrist’s annual report 2008–09
• working with mental health services to improve standards of treatment and care, and the
application of the Act to clinical practice
• providing policy and clinical advice to the Mental Health, Drugs and Regions Division, government
and other mental health stakeholders
• providing departmental and ministerial briefings about critical incidents
• examining and providing advice on sentinel events or critical incidents under the auspices of the
Quality Assurance Committee
• reviewing the suitability of ECT licensing in the public and private sectors
• performing statutory functions relating to patients detained under the Sentencing Act 1991 and
Crimes Mental Impairment (Unfitness to be Tried) Act 1997
• undertaking and promoting quality improvement initiatives and projects relating to mental health
treatment and care
• developing clinical guidelines
• delivering education and training
• participating on working parties and interdepartmental committees about the welfare of persons
receiving treatment or care for a mental illness.

Chief Psychiatrist’s annual report 2008–09 3
2 Statutory reports for 2008–09
2.1 What services must report
The Mental Health Act requires mental health services to report monthly to the Chief Psychiatrist
on the use of seclusion, mechanical restraint and ECT. These reports are known as the ‘statutory
reports’ and they enable the Chief Psychiatrist to monitor the use of these practices, including
trends over time.
The Act also requires mental health services to report the annual medical examination of
involuntary patients who have been in continuous care for 12 months, as well as the death of any
patient that is a ‘reportable death’, within the meaning of the Coroners Act 2008.
Electronic reporting was introduced in October 2006 for seclusion and mechanical restraint
reporting. Services now record each occurrence of these practices on their local client
management information (CMI) system, and submit data electronically via the statewide mental
health information system known as the Operational Data Store (ODS). Electronic reporting of ECT
also commenced in 2008.
Eliminating the potential for errors inherent in a paper-based system should ensure more efficient
data handling and improved data integrity. Integration of this information into the CMI also enables
services to interrogate their own client information systems to monitor the occurrence of these
practices in the context of the broader clinical and demographic information recorded for their
client population.
To provide some context to the data, the total number of consumers treated by public mental health
services was 59,986 in 2008–09 and 59,362 in 2007–08. Consistent with contemporary practice,
the majority of these consumers received their treatment in the community. Only 21 per cent of
these consumers had a hospital admission during 2008–09 and 24 per cent in 2007–08.
2.2 Seclusion
Section 82(1) of the Act defines seclusion as:
‘the sole confinement of a person at any hour of the day or night in a
room of which the doors and windows are locked from the outside’.
Under the Act a person receiving treatment in a public mental
health service can be secluded if it is necessary to protect them or
others from an immediate or imminent risk to their health or safety
or to prevent them absconding. Seclusion should only be used as
an intervention of last resort when a person is unable to be treated
less restrictively. Seclusion is not permitted in a private psychiatric hospital.
Seclusion
For more information
on minimum practice
standards on seclusion,
see: Clinical guideline on
seclusion (Department
of Health, 2006).
A registered nurse must review the secluded person at least every 15 minutes and a medical
practitioner must examine the person at least every four hours (unless this is varied by an authorised
psychiatrist). Each seclusion episode must be recorded and reported to the Chief Psychiatrist.

4 Chief Psychiatrist’s annual report 2008–09
2.2.1 Seclusion episodes
A total of 5,838 seclusion episodes were reported in 2008–09, a 13 per cent reduction compared
to the preceding financial year (6,681 episodes). The number of individual clients secluded fell by
six per cent, from 1,913 to 1,803.
There were 59,986 registered clients of public mental health services in Victoria in 2008–09, of
whom three per cent experienced seclusion at some time in the course of their treatment. Of those
admitted to hospital 1 during the reporting period, 14 per cent (1,803 consumers) were secluded at
some time during their admission (compared to 15 per cent, or 1,913 consumers, in 2007–08).
Figure 1: Trend in use of seclusion from 2003-04 to 2008-09
Figure 1 shows that the number of seclusion episodes peaked in 2006–07 and has declined by
23 per cent since, even though the bed capacity in public mental health services increased over
this period 2 , as did the number of inpatient admissions.
1 Across all inpatient units, including child and adolescent, adult acute, aged, general specialist, forensic and secure
extended care.
2 Additional short-stay beds in psychiatric assessment and planning units (PAPUs) came on line over this period.

Chief Psychiatrist’s annual report 2008–09 5
Figure 2: Duration of seclusion episodes from 2003-04 to 2008-09
Figure 2 shows the changes in the use of seclusion since 2003–04, with both short episodes
(under four hours) and long episodes (over 12 hours) becoming more common over this time.
There has been a progressive reduction over the past three years, particularly noticeable in
relation to short episodes.
2.2.2 Persons secluded
Figure 3: Number of seclusion events within the same hospital admission

6 Chief Psychiatrist’s annual report 2008–09
Fourteen per cent of patients hospitalised during the reporting period were secluded. As Figure 3
shows, more than half of these (55 per cent in 2008–09) were secluded only once in the course
of their admission. More than a quarter (27 per cent in 2008–09) were secluded twice or three
times in the course of their admission and a small group of clients (nine per cent in 2008–09)
who needed to be secluded in the course of their hospitalisation were secluded on more than six
occasions. This small group of patients with highly problematic behaviours accounts for a high
proportion of all seclusion episodes.
Sixty-two per cent of seclusion episodes involved a male consumer. Males account for most
episodes of seclusion in adult and aged persons mental health services. This pattern is reversed
in child and adolescent mental health services (CAMHS), where 112 females were secluded in
2008–09 (56 per cent of all episodes).
In the reporting period, the majority (91 per cent) of all seclusion episodes occurred in adult
inpatient units (a total of 5,287 episodes). Seclusion was relatively rarely used in aged inpatient
units (344 episodes in 2008–09, or six per cent of the total) and in child and adolescent inpatient
units (201 episodes, constituting three per cent of the total).
Consumers aged between 20 and 29 were most likely to be secluded (32 per cent of all seclusion
episodes), followed by consumers aged 30–39 (27 per cent) and those aged 40–49 (16 per cent).
2.2.3 Reasons for seclusion
As in 2007–08, the primary reasons for secluding a patient were to prevent an immediate or
imminent health or safety risk to the consumer or others. Figure 4 provides further detail.
Figure 4: Reasons for seclusion

Chief Psychiatrist’s annual report 2008–09 7
2.3 Mechanical restraint
Mechanical restraint is defined in section 81(1A) of the Act as:
‘the application of devices (including belts, harnesses, manacles,
sheets and straps) on the person’s body to restrict his or her
movement, but does not include the use of furniture (including
beds with cot sides and chairs with tables fitted to their arms) that
restricts the person’s capacity to get off the furniture’.
Mechanical restraint can only be applied if necessary for the
person’s medical treatment, or to prevent a person causing injury
to themselves or any other person, or to prevent a person from
persistently destroying property. Like seclusion, mechanical
restraint should be an intervention used only when all alternative
options have been tried or considered and excluded.
Mechanical restraint
For more information
on minimum practice
standards on the use
of mechanical restraint,
see: Chief Psychiatrist’s
guidelines on mechanical
restraint (Department of
Health, 2006).
A registered nurse or medical practitioner must continuously observe a restrained person and a
registered nurse must review the person at least every 15 minutes. A medical practitioner must
examine the restrained person at least every four hours (unless varied by an authorised psychiatrist).
Each restraint episode must be appropriately recorded and reported to the Chief Psychiatrist.
2.3.1 Restraint episodes
There were 822 episodes of mechanical restraint in 2008–09: a decrease of 12 per cent compared
to 2007–08 (934 episodes).
Figure 5: Trend in use of mechanical restraint from 2003-04 to 2008-09
Figure 5 shows that the number of mechanical restraint episodes has declined from a peak of
1,160 episodes in 2004–05 to 822 episodes in 2008–09 (a 29 per cent reduction). While the
number of inpatient admissions has increased by 12 per cent since 2004–05, the number of clients
restrained increased by only nine per cent over the same period.

8 Chief Psychiatrist’s annual report 2008–09
Figure 6: Duration of restraint episodes, 2003–04 to 2008–09
As shown in Figure 6, most restraint episodes were under four hours in duration (80 per cent of
episodes in 2008–09, down from 91 per cent in the previous year). Five per cent of episodes lasted
between four and 12 hours (down from seven per cent in 2007–08). The proportion of episodes of
restraint exceeding 12 hours in duration increased from two per cent in 2007–08 to 15 per cent in
2008–09.
The median duration of restraint was 220 minutes in adult mental health services, 165 minutes
in aged persons mental health services and 90 minutes in child and adolescent mental health
services.
2.3.2 Persons restrained
There were 180 persons restrained in 2008–09, constituting a three per cent increase compared to
2007–08, when 174 persons were restrained.
Approximately one per cent of patients hospitalised during the reporting period were mechanically
restrained. As Figure 7 shows, almost half of those restrained (45 per cent) would have experienced
a single episode of restraint in the course of their admission. Fifty-five per cent of clients who were
restrained experienced multiple episodes of mechanical restraint in the course of their admission.
A small group of patients with highly problematic behaviours accounts for a high proportion of
all restraint episodes. For example, in 2008–09 one single client accounted for 13 per cent of all
restraint episodes and for 56 per cent of the total duration of restraint provided across the state.
Reviews of the data undertaken by the Office of the Chief Psychiatrist identify outliers of this kind
for clinical discussion with the relevant mental health service. This ensures that appropriate reviews
occur, including seeking a second opinion, so that treatment and care are provided in the least
restrictive manner possible, in accordance with the Act and the Victorian Charter of Human Rights
and Responsibilities Act 2006.

Chief Psychiatrist’s annual report 2008–09 9
Figure 7: Number of restraint events within the same hospital admission
2.3.3 Gender and age
Seventy-six per cent of restraint episodes involved a male consumer (62 per cent in 2007–08).
Figure 8: Trends in the use of mechanical restraint by age group,
2006–07 to 2008–09

10 Chief Psychiatrist’s annual report 2008–09
In spite of the decrease in the overall use of restraint across the state, the use of restraint in adult
mental health services has more than doubled, from 27 per cent of all episodes in 2007–08 to 58
per cent in 2008–09. Conversely, the use of restraint in aged persons mental health services fell,
from 70 per cent of all episodes in 2007–08 to 39 per cent in the reporting period.
The significant increase in the use of restraint in adult mental health services in 2008–09 can
be attributed largely to a single patient, whose treatment accounts for 13 per cent of all restraint
episodes. The Office of the Chief Psychiatrist has followed up this client’s treatment with the
service concerned. In addition, analysis of restraint data by the Office of the Chief Psychiatrist has
identified 50 restraint episodes of extremely short duration (most of them as short as one minute).
This is related to a new practice, in some services, of reporting all instances where a client has to
be briefly restrained at the start of a seclusion episode. This reporting practice has the unintended
effect of distorting statewide restraint data and will be reviewed by the Chief Psychiatrist.
2.3.4 Reasons for restraint
As in 2007–08, the largest single reason for using mechanical restraint was to prevent harm or
injury to the person themselves. The next main reason was to prevent harm or injury to another
person.
Figure 9: Reasons for mechanical restraint

Chief Psychiatrist’s annual report 2008–09 11
2.4 Electroconvulsive therapy (ECT)
ECT is a procedure performed under short general anaesthetic
in which modified seizures are induced by the selective passage
of an electrical current through the brain. Representations of
ECT in popular culture have tended to generate negative public
perceptions of the practice despite significant advances in ECT
technology and knowledge over recent years.
Most commonly prescribed for severe depression, ECT may also
be used for other types of serious mental illness such as mania,
schizophrenia, catatonia and other neuropsychiatric conditions.
It may be life-saving for some patients who have not responded
to other treatments and is most often prescribed as part of a
treatment plan in combination with other therapies.
Electroconvulsive
therapy
For more information
on minimum practice
standards on ECT, see
the Electroconvulsive
therapy manual.
Licensing, legal
requirements and clinical
guidelines (Department
of Health, 2009)
The Act contains specific provisions regulating consent to ECT and the circumstances under which
a patient may give informed consent to ECT and also under which the authorised psychiatrist can
provide substitute consent to ECT for involuntary patients 3 . The Act also requires any public or
private mental health service administering ECT to comply with certain procedures and standards,
and report monthly to the Chief Psychiatrist on ECT use.
The Act establishes a framework for the licensing of premises. ECT can only be provided in premises
licensed by the Secretary to the Department of Health. In practice this power is delegated to the
Chief Psychiatrist 4 . Licences may be granted for up to five years.
ECT can be administered as a course (a number of consecutive single treatments) or as a periodic
continuation or maintenance therapy following an acute phase of illness.
2.4.1 Use of electroconvulsive therapy in 2008–09
Number of treatments
A total of 19,558 ECT treatments were given in 2008–09, an increase of 10 per cent compared to
2007–08. Sixty-two per cent of all ECT treatments were provided by public mental health services
and 38 per cent by private psychiatric hospitals.
3 See Part 5, Div 2.
4 See sections 72–80 of the Act.

12 Chief Psychiatrist’s annual report 2008–09
Figure 10: Use of ECT from 2003–04 to 2008–09
Figure 11: Administration of ECT by sector from 2003–04 to 2008–09
Figure 11 shows that the use of ECT in public mental health services has increased by nine per
cent since 2003–04. This increase appears to be broadly consistent with population growth 5 and
service utilisation trends 6 over the same period. In the private sector, the use of ECT increased by
68 per cent over the same period, from 4,407 treatments in 2003–04 to 7,383 in 2008–09. This
may reflect an increase in the number of beds in the private sector, combined with the increasing
provision by the private sector of ECT treatment to patients who are experiencing more severe
episodes of high prevalence disorders, like depression.
5 The Victorian population increased by six per cent between 2003 and 2007 (source: DHS Info Centre).
6 The number of consumers admitted to an inpatient unit rose by 12 per cent between 2003–04 and 2008–09
(source: RAPID).

Chief Psychiatrist’s annual report 2008–09 13
2.4.2 Persons receiving ECT treatment
In 2008–09 a total of 1,791 people (1,146 public and 645 private) received ECT treatment, roughly
the same as in the previous year. This represents three per cent of the total number of patients
treated in the public mental health system annually. The average number of treatments per person
was 11, which is consistent with acceptable contemporary practice.
Sixty-four per cent of treatments in the public sector were administered to patients consenting
to their own treatment and 36 per cent were administered to involuntary patients where the
authorised psychiatrist consented on their behalf. Involuntary treatment can only occur in a public
mental health service proclaimed under the Act.
Women received 67 per cent of all ECT treatments in 2008–09. This finding remains consistent with
previous years and international findings on ECT usage patterns by gender 7 .
Figure 12: ECT treatments by age and gender in 2008–09
Women aged 50 to 59 received more ECT treatment (2,267 procedures) than other age groups. The
same age bracket was also the peak decade for males receiving ECT (1,144 treatments), followed
by males in their thirties (1,112 treatments). In the 10–19 year old group, 163 ECT procedures were
administered to 18 and 19 year-olds. In addition, 46 treatments were administered to seven young
people under 18. The Deputy Chief Psychiatrist, Child and Youth Mental Health, has discussed the
use of ECT for young people under 18 with the services involved and received advice that the use of
ECT in these rare cases was indicated on the basis of the diagnosis and severity of illness and that,
when considering the use of ECT to treat clients under 18, a second opinion was sought in each
case. At the other end of the spectrum, 131 ECT procedures were provided to persons over 90 years
of age. Because of the small percentage of ECT treatment represented by these procedures (≤1 per
cent), neither age group is included in figure 12.
7 Olfson M et al, 1998, ‘Use of ECT for the inpatient treatment of recurrent major depression,’ American Journal of
Psychiatry, 155:22-24.

14 Chief Psychiatrist’s annual report 2008–09
2.4.3 Diagnosis
ECT treatment was given most often for a diagnosis of major affective disorder followed by
schizophrenia and other affective and somatoform disorders, reflecting the generally accepted
clinical indications for its use.
Table 1: Number of ECT treatments by diagnosis 8
Diagnosis Treatments Percentage
Mood [affective] disorders 14,773 76%
Schizophrenia, schizotypal and delusional disorders 3,754 19%
Other (including neurotic illness) 139

Chief Psychiatrist’s annual report 2008–09 15
In addition, the process enabling mental health services to electronically lodge an encrypted
monthly ECT report to the Chief Psychiatrist was improved by the introduction of a new data
validation process.
2.5 Annual examinations
Section 87 of the Act requires that every patient must have a
mental and general health examination at least once a year.
The authorised psychiatrist must submit a report of the examination
to the Chief Psychiatrist.
Increasingly, mental health consumers attend a local general
practitioner for their physical health needs as would any other
member of the community. However, given the known increased
morbidity of consumers with a mental illness and tendency to
poorer health status, the authorised psychiatrist of each approved
mental health service has a responsibility for ensuring each
consumer’s health status is appropriately reviewed.
The Chief Psychiatrist reviews all Annual examination of patient
forms submitted and may request further information from a service
if necessary.
2.6 Reportable deaths
Under the Act an authorised psychiatrist of an approved mental
health service or a person in charge of any other ‘psychiatric
service’ must report the death of any person receiving treatment or
care for a mental disorder, which is a reportable death within the
meaning of the Coroners Act.
The Chief Psychiatrist’s reportable deaths guideline also requires
that services report the death of any currently registered mental
health consumer if it is unnatural or unexpected, and where they
become aware of the unexpected death of a consumer who was a
registered client within the preceding six months.
Annual examination
For further information
relating to the
responsibilities of mental
health services under s.87
of the Act, see: General
medical health needs,
annual examination, nonpsychiatric
treatment,
special procedures
and medical research
procedures (Department
of Health, 2008).
Reportable deaths
For further information
regarding the
responsibilities of
mental health services
under s.106A of the
Act, see: Reportable
deaths (Department of
Health, 2004).
The Chief Psychiatrist reviews the report to identify any clinical, service or system issues of concern.
The Chief Psychiatrist may ask for further information from the service or, if the circumstances
surrounding the death cause concern, may conduct a formal investigation under the Act.
The principal purpose of reporting a death to the Chief Psychiatrist is to enable the Chief
Psychiatrist to identify and then act upon any systemic clinical issues. For example, if deaths appear
related to treatment from a particular service component, or in greater numbers at a particular
service, it may lead to a reconsideration of clinical practice in areas such as risk assessment or
discharge. In some cases an urgent inquiry may be indicated, such as following an inpatient death.
This is particularly important as the coronial process may take some time before a final outcome is
achieved and recommendations are made.

16 Chief Psychiatrist’s annual report 2008–09
It is the Coroner’s role to determine the cause of death and any contributing factors. The Chief
Psychiatrist registers an interest with the Coroner to ensure the office receives the Coroner’s
findings and any recommendations.
In reporting a death, services submit the information available to them at the time they are notified
of the death. This may vary depending on when the deceased person last had contact with the
service or what details are known about the circumstances of the death. Services are required
to describe the manner of death and identify whether a death appears to be:
• ‘unexpected, unnatural or violent’
• due to ‘natural causes’ related to a medical condition or old age
• of unknown cause.
Suspected suicide was discontinued as a reporting category in 2008–09. Suspected suicides are
now effectively included under the ‘unexpected, unnatural or violent’ category, together with deaths
that, while ‘unexpected, unnatural or violent’, are not demonstrably indicative of suicide. Examples
of the latter include deaths in a motor car accident, by drowning or in a house fire. Only a coroner
of the State Coroner’s Office of Victoria can legally determine the underlying cause of a death,
including a finding of suicide; 9 and such determination may be made some time after the year
in which the death occurred.
2.6.1 Profile of deaths reported in 2008–09
The death of 503 consumers was reported to the Office of the Chief Psychiatrist in 2008–09.
Of these, 66 per cent were male (331 consumers) and 34 per cent (171 consumers) were female.
The gender split in 2007–08 was 62 per cent males (261 consumers) and 38 per cent females
(157 consumers). Thirty-nine per cent of reported deaths were attributed to natural causes.
Figure 13: Reportable deaths by cause, 2008–09
9 Suicide refers to the deliberate taking of one’s life. To be classified as a suicide, a death must be recognised as
due to other than natural causes and it must be established by a coronial inquiry that the death has resulted from
a deliberate act of the deceased with the intention of taking his or her own life. Australian Bureau of Statistics:
Suicides 2006.

Chief Psychiatrist’s annual report 2008–09 17
Figure 14: Reportable deaths by cause and gender, 2008–09
Figure 14 shows that male consumers accounted for 62 per cent of all reportable deaths
and for 67 per cent of all unexpected, unnatural or violent deaths in 2008–09.
Figure 15: Reportable deaths by age, 2008-09
Figure 15 shows the distribution of reportable deaths by age group. All reportable deaths for
consumers under 20 years of age were classified unexpected, unnatural or violent (U/U/V).
This proportion decreases to 18 per cent of reportable deaths of consumers over 90.
The highest peak of mortality not attributable to natural causes is among clients, or former
clients, in their thirties.

18 Chief Psychiatrist’s annual report 2008–09
A clinical diagnosis was recorded for 458 of the 503 reportable deaths recorded in 2008–08
(91 per cent). As shown in Table 2, the most frequent mental illnesses associated with a reportable
death were psychosis (schizophrenia or other psychotic disorders) and mood disorder. This reflects
the profile of consumers treated by public mental health services, which tends to be those with a
serious mental illness.
Table 2: Reportable deaths in 2008–09 by diagnostic group
Diagnostic group Number of deaths Percentage
Psychosis 153 33
Dementia and organic brain disorder 123 27
Mood disorder 109 24
Personality disorder 20 4
Substance-related disorders 20 4
Adjustment disorder 17 4
Anxiety disorder 6 1
Other 10 2
Total 458
2.6.2 Coronial recommendations
Throughout the year the Chief Psychiatrist reviews and collates coronial findings, recommendations
and practice themes and disseminates summaries to area mental health services to promote
quality improvement.
In 2008–09, quality improvement themes from coronial recommendations received by the
Chief Psychiatrist related primarily to the management of consumers on community treatment
orders. A thematic summary was sent to the clinical directors and managers of all mental health
services with a request to consider the information and recommendations in the context of their
local policies and practices. The recommendations covered areas such as discharge planning,
information sharing and education of family and other carers, and monitoring use of illicit
substances.
Copies of the circulars may be found on the Office of the Chief Psychiatrist website at
www.health.vic.gov.au/chiefpsychiatrist/corep.htm.

Chief Psychiatrist’s annual report 2008–09 19
3 Contacts, complaints and enquiries
The Chief Psychiatrist’s office receives a large number of contacts — by telephone and written —
from consumers, carers, service providers, members of the public and others. Ease of access to the
knowledge and advice provided by the office is important, especially for mental health service users
and their families. The office makes every effort to respond promptly to calls and written enquiries,
and to provide informed and helpful advice.
Effective complaints management systems in mental health services are important in safeguarding
the rights of the mentally ill. They provide a voice for consumers and carers and an opportunity
for service providers to improve the quality of services. While the Act does not define a specific
complaints function for the Chief Psychiatrist, it does give him or her power to enquire regarding
the treatment and care of any individual and to investigate complaints or concerns. The Chief
Psychiatrist responds to complaints as part of this broader statutory responsibility for the medical
care and welfare of patients.
The Victorian Health Services Commissioner is the principal body for health services complaints,
and receives some complaints about mental health services. 10 Complaints to the Commissioner
must be from the consumer themselves, or their nominee, and be confirmed in writing. The
Health Services Commissioner has legislated powers of conciliation, investigation and enquiry
but no powers to make treatment decisions. The Health Services Commissioner may refer a
complaint to the Chief Psychiatrist where the Chief Psychiatrist’s jurisdiction is more applicable,
and vice versa, or they may work together on a complaint to try to reach a resolution for the
person. A memorandum of understanding between the Chief Psychiatrist and the Health Services
Commissioner was finalised in 2008–09. The document outlines how the two bodies can work most
effectively in addressing complaints about mental health services and provides a protocol for the
sharing of complaint-related information.
Health services are expected to have local complaints systems for all health service users, including
mental health consumers. Complainants are encouraged to lodge their complaint at the local level
first. A range of other bodies, such as the Ombudsman and Public Advocate, also provide an avenue
of appeal if the complainant is dissatisfied with the way in which their complaint has been handled,
as do the relevant health registration boards governing the conduct of health care professionals.
Consumers and carers and peak consumer and carer organisations have expressed concern about
the quality and variability of existing complaints mechanisms. In response, the Minister for Mental
Health engaged the Consumer and Carer Subcommittee of the Ministerial Advisory Committee
in 2008 to review complaints management processes in selected mental health services with a
view to identifying learning points that could be applicable across the sector. The outcomes of this
project will inform the future direction for mental health complaints management.
3.1 Responding to contacts
The administrative staff of the Office of the Chief Psychiatrist are generally the first point of contact
and can deal with some enquiries or refer callers appropriately. Often these are simple queries
about finding a mental health service and the person is either given the contact details or referred
to the website at www.health.vic.gov.au/mentalhealth/services. A free call telephone number
(1300 767 299) was introduced in 2005 to facilitate contact with the office.
10 The Health Services Commissioner’s annual report can be accessed at
www.health.vic.gov.au/hsc/resources/annualrep

20 Chief Psychiatrist’s annual report 2008–09
Where the issue is more complex, or involves a complaint or a clinical matter, the enquirer or
complainant is referred to a clinical adviser. Clinical advisers are experienced mental health
clinicians with an extensive knowledge of the service system and mental health treatment issues.
Clinical advisers are appointed as authorised officers of the Chief Psychiatrist to exercise powers
under the Act and assist the Chief Psychiatrist in carrying out the statutory functions.
Complainants are initially encouraged to use the local mental health or health service complaints
system to resolve their issue locally where possible. A clinical adviser will assist the person to
exercise their rights by providing information regarding the implications of the relevant legal status
under the Act, their rights and the options available. Where the complainant has tried local avenues
without satisfaction, or for some reason is unable to raise the matter locally, the clinical adviser
will try to resolve the issue for the person in consultation with the Chief Psychiatrist, as necessary.
Often this will involve contact (with the consent of the complainant) with the treating service or
others involved in providing care to the person to better understand their situation.
Service providers and clinicians also contact the office seeking advice on aspects of clinical
practice or service delivery; the Minister for Mental Health and other government departments also
refer matters to the Chief Psychiatrist for advice and action. This diversity of contacts to the office
provides valuable information about issues of concern for consumers, carers and service providers;
and the quality of services delivered.
3.1.1 Profile of contacts received by the office
A new complaints database was introduced in January 2007 to improve the management of
complaints to the office. Contacts are now categorised according to the type of contact — enquiry,
complaint or notification (episode type), the person making the contact (initiator), the method of
contact (telephone or written) and the primary issue of the contact (primary concern).
Figure 16: Number and type of contacts from 2007 to 2008–09

Chief Psychiatrist’s annual report 2008–09 21
The office responded to 1,538 recorded contacts in 2008–09, a 50 per cent increase over 2007–08.
Some of this variation, such as the number of enquiries more than doubling, may be attributable to
more rigorous recording by the office of contacts using the data management system introduced in
2007. There was a moderate increase in the number of complaints received. There was a significant
increase in the number of requests for clinical advice and in the number of incidents reported to
the office by area mental health services and the Department of Health. The latter were typically
reported to the Office of the Chief Psychiatrist for information only, with follow-up action in the
wake of the incident being progressed through established internal processes in the health service.
The greatest number of contacts were made by service providers (29 per cent—down from
33 per cent in 2007–08). Consumers accounted for another 25 per cent of contacts, as did
carers and families, constituting a slight increase for consumers and a slight decrease for carers
and families when compared to the previous year. Eight per cent of contacts were made by
members of the public.
The number of contacts made by phone further increased, from 70 per cent in 2007–08 to
76 per cent in the reporting period. The remaining contacts were made in writing.
3.2 Complaints
Every effort is made to resolve complaints by telephone without the consumer or complainant
needing to put their complaint in writing. This generally provides a speedier and more personal
response for the complainant, especially where the concern is a current treatment matter, as they
frequently are. Where the issue is more complex, the complainant is asked to provide written details
to enable further investigation. In the reporting period, 82 per cent of complaints were made by
telephone (up from 70 per cent in 2007–08); the remaining 18 per cent in writing.
Most complaints are addressed through liaison and negotiation with the relevant mental health
service or clinician, often to reconnect the consumer or relative and the service or clinician so
that their concerns can be discussed and addressed. Many complaints are about differences of
opinion regarding the need for mental health care, or the manner in which treatment has occurred,
with consequent impact on the consumer–clinician relationship. For mental health consumers this
relationship is especially important since, unlike the general health care system, they are required
to receive their treatment from the area mental health service responsible for the catchment area in
which they live.
The Chief Psychiatrist may write to the authorised psychiatrist of a service requesting a clinical
report to assess the treatment and care provided. In a small number of cases, the Chief Psychiatrist
will personally meet with the patient, review the case and provide recommendations to assist in
reaching a satisfactory outcome for the complainant. A formal direction may be made in instances
where less formal approaches fail to achieve a resolution or desired action. In practice, this is
seldom necessary. A complaint is closed when the Chief Psychiatrist decides that all steps have
been taken to resolve the issue. Where the interaction has been protracted, or the issues complex,
the Chief Psychiatrist’s opinion and decision will be conveyed to the complainant in writing.

22 Chief Psychiatrist’s annual report 2008–09
3.2.1 Profile of complaints
The Office of the Chief Psychiatrist received 435 complaints in the course of 2008–09, an
increase of 22 per cent when compared to 2007–08, when 358 complaints were received.
To provide some context, it should be noted that there were just over 60,000 registered
consumers in the 2008–09 year.
Most complaints were made by consumers (52 per cent) and carers (33 per cent). Other complaints
were lodged by members of the public (four per cent), service providers (three per cent), staff (two
per cent), other consumers (two per cent) and others (four per cent). A small number of consumers
lodge repeated complaints with the office.
Just over half the complaints (52 per cent) related to a consumer in a community-based service
and 43 per cent to a consumer in an inpatient unit. The remaining complaints included two PDRSS
clients, four clients of private mental health services and 18 records where the ‘service type’ field
was left blank.
Most complaints (85 per cent) related to adult mental health services, with far fewer complaints
relating to child and adolescent mental health services (one per cent) and aged persons mental
health services (10 per cent). This distribution may reflect the higher proportion of adult clients
on involuntary treatment orders and the relatively greater pressure on bed-based and community
adult services. The increased time commitment of the Deputy Chief Psychiatrist, Aged Persons
Mental Health and the appointment of a Deputy Chief Psychiatrist, Child and Youth Mental Health
are expected to strengthen the capacity of the office to better engage these service areas in the
complaints process from 2009–2010.
Complaints are grouped below according to the primary concern. In practice many complaints
straddle several areas and are not easily categorised. As figure 17 shows, most complaints were
broadly about treatment and care, followed by complaints in relation to involuntary treatment and
access to services.
Figure 17: Complaints received by the OCP in 2007–08 and 2008–09

Chief Psychiatrist’s annual report 2008–09 23
Treatment and care
Complaints about aspects of treatment and care made up 48 per cent of all consumer complaints
in 2008–09 and 52 per cent of all carer and family complaints. They covered a range of concerns,
including complaints about clinicians and requests to change a treating doctor or case manager,
communication issues between clinicians and consumers, disagreement about diagnosis, lack of
discharge arrangements and expected follow-up care and lack of carer support and involvement.
Medication issues, both the need for it and problematic side effects were also raised. Other issues
included access to leave for detained involuntary patients, inpatient amenities, and either perceived
inadequate service response or the opposite — a preference for no service response.
Involuntary treatment
Involuntary treatment was the second most frequent cause of complaint, underpinning 31 per cent
of all consumer complaints in 2008–09, but was rarely the subject of complaint from families
and carers or others. Combined, complaints about involuntary treatment and statutory practices
increased from 18 per cent of complaints in 2007–08 to 23 per cent in 2008–09.
Many complaints centred on objections to being placed on an involuntary treatment order or
community treatment order, concerns about the basis for the order and the perceived restriction
of liberty and movement. Others concerned the lack of choice in determining treatment options,
such as second opinions and changing services, and fears about being admitted to hospital if
noncompliant with the order.
Many consumers disagreed that they had a mental illness and believed they had been wrongfully
detained in a mental health service. In such circumstances consumers were advised of their appeal
rights under the Act and provided with relevant contact details, including the Mental Health Review
Board and Mental Health Legal Service. Clinical advisers frequently followed up the complaint with
the relevant service to verify the circumstances of detention and to convey the consumer’s distress
to the treating team, with a request that further explanation and support be provided to the person
along with all assistance in helping them exercise their rights.
Access to services
Access to services was the second most frequent cause of complaint for families or carers,
constituting 30 per cent of complaints to the office, and the cause of complaint in 64 per cent of
cases of service providers contacting the office.
Concerns in this area included access to appropriate services, including mental health assessment,
crisis team and triage response, inter-service transfer, dual diagnosis services, psychiatric disability
and rehabilitation support, and access to bed-based services such as community care units, secure
extended care units and other forms of supported residential accommodation. A key theme was
difficulties in gaining access to the desired level of service and support at the time it was needed.
Statutory practices
The number of questions or concerns about ECT treatment rose from four in 2007–08 to 14 in the
reporting period. The number of complaints about seclusion practices fell from three complaints in
2007–08 to a single complaint in the reporting period. There were no complaints about mechanical
restraint in the reporting period.

24 Chief Psychiatrist’s annual report 2008–09
Legislation and policy
A small number of complaints were about aspects of the Mental Health Act or other legislation
or departmental policy, such as the catchment area policy, and the defined target populations
for services.
Incidents
Four complaints were classified as ‘incidents’ occurring in a mental health service, including two
cases of alleged assault.
Other
The ‘Other’ category included a wide array of issues including such matters as court and judicial
processes, accommodation issues, government policies, other government-funded services and
non-specific complaints.
3.3 Enquiries
A large number of calls were from people seeking advice on how to access a service; often simply
how to contact a public mental health service. Others wanted to discuss potential avenues of
treatment and care for an ill relative or employee and were uncertain whether to intervene or how to
proceed. Some sought information on various disorders and treatments. Advice provided by clinical
advisers or the Chief Psychiatrist often helps to alleviate concerns or clarify possible actions so that
the person feels more empowered to assist the individual about whom they may be concerned. The
establishment of a 24-hour mental health telephone advice line, which will be operational from late
2009, may divert some of these calls.
3.3.1 Clinical advice
Mental health service clinicians contacted the Office of the Chief Psychiatrist to seek information
and advice on a wide range of issues, the largest single area being the application of the Mental
Health Act. These enquiries often relate to the process of recommendation for involuntary
treatment and the negotiation between services regarding who will supervise a community
treatment order when a patient moves between areas. Other common areas were advice about
the management of consumers with complex presentations, aspects of treatment, accessing
appropriate services, chief psychiatrist guidelines and departmental and divisional policies.

Chief Psychiatrist’s annual report 2008–09 25
4 Investigations
Under section 106 of the Mental Health Act the Chief Psychiatrist and authorised officers have
powers to visit a psychiatric service and carry out investigations, if the Chief Psychiatrist forms the
view that such action is necessary. This may include inspecting premises and records held by the
service, making enquiries about a person’s treatment, seeing a person who is receiving treatment
and interviewing staff. The Chief Psychiatrist also has power to formally direct a service to cease or
implement a particular treatment or clinical action where deemed appropriate and necessary.
In practice the Chief Psychiatrist more frequently addresses concerns through discussion and
negotiation with the relevant mental health service, generally through the authorised psychiatrist
or clinical director. As part of this process, the Chief Psychiatrist may seek a written formal report
from the service, request and examine a copy of a person’s medical record, meet with the relevant
clinicians, and interview the consumer and/or their carer to assist in determining the most
appropriate action. The Chief Psychiatrist will also discuss issues raised by statutory reporting and
complaints or contacts during service visits.
Three formal investigations were conducted during the 2008–09 financial year. Two of these
followed complaints regarding the appropriateness of admission and the treatment and care
provided, in particular, whether the amount of seclusion authorised was clinically necessary and
in compliance with the Act. The third comprised a clinical review and inquiry in the context of a
number of inpatient deaths.
In May 2008 the Minister for Mental Health announced a review of the Mental Health Act to
examine whether the Act provides an effective legislative framework for the treatment and care
of people with a serious mental illness in Victoria. As part of the review, various functions of the
Chief Psychiatrist were considered, including monitoring functions and powers and the handling
of complaints. The review panel conducted an extensive community consultation process in the
course of 2008–09, which is described in its consultation report 11 . Drafting instructions for the new
legislation are expected to be finalised in 2009–10.
11 Department of Health (2009): Review of the Mental Health Act 1986. Community consultation report.

26 Chief Psychiatrist’s annual report 2008–09
5 Working with the sector
The Chief Psychiatrist undertakes a number of activities with the mental health service sector to
proactively and collaboratively address treatment and service system issues as part of a continuing
process of service improvement.
Clinical advice
As noted in the ‘Contacts, complaints and enquiries’ section of this report, mental health service
clinicians frequently contact the office seeking clinical advice, and this trend appears to be
increasing. Besides providing information and guidance, the Chief Psychiatrist’s capacity to mediate
service system issues such as inter-service and interstate transfers, and to facilitate access to
specialist services and encourage inter-service cooperation, can improve consumer outcomes by
making the best use of available resources in a service system facing high levels of demand. During
the reporting period, there were particular issues regarding access to secure extended care beds
by rural area mental health services and forensic mental health without this service component.
A number of meetings and service visits were carried out to negotiate more equitable access and
to support referral and discharge arrangements for out-of-area patients.
Authorised psychiatrists
Each approved mental health service must appoint an authorised psychiatrist, who is a qualified
psychiatrist employed by the health service 12 . The authorised psychiatrist has specific powers,
duties and functions under the Act including overall responsibility for the treatment and care
of persons in the mental health service, and the power to consent to treatment on behalf of an
involuntary patient. The authorised psychiatrist may also delegate any of their powers, duties and
functions under the Act to another qualified psychiatrist (known as a delegated psychiatrist), except
the power of delegation or the duty to provide the Forensic Leave Panel with information.
The Mental Health Review Board and the Secretary of the Department of Health must be notified
of each authorised psychiatrist’s appointment within five days. In practice, the Secretary delegates
this function to the Chief Psychiatrist. The Office of the Chief Psychiatrist maintains a register of all
authorised psychiatrists.
The Chief Psychiatrist also provides advice on the suitability of psychiatric qualifications obtained
by overseas trained psychiatrists to the Medical Practitioners Board of Victoria in relation to their
registration as specialist psychiatrists.
12 Section 96, Mental Health Act.

Chief Psychiatrist’s annual report 2008–09 27
5.1 Clinical leadership
As part of the statutory responsibility for standards of treatment and care, the Chief Psychiatrist
conducts a range of activities to provide clinical leadership and facilitate practice and service
development.
5.1.1 Authorised Psychiatrists Forum
The Chief Psychiatrist convenes the quarterly Authorised Psychiatrists Forum to assist authorised
psychiatrists in fulfilling their functions, and to provide an opportunity for peer support in dealing
with issues of common interest and concern. During the reporting period, issues discussed
included:
• clinical guidelines under development
• the impact of the Charter of Human Rights and Responsibilities
• specialist eating disorder services and the role of area mental health services
in responding to people with eating disorders
• reportable deaths and sentinel events
• smoking in inpatient units
• access to secure extended care beds
• the review of the Mental Health Act
• the Mental Health Reform Strategy 2009–2019.
5.1.2 Aged persons mental health forums
The Office of the Chief Psychiatrist also holds four-monthly forums with clinical directors and senior
clinicians from the aged persons mental health sector. The purpose of these forums is to provide
education, exchange information and identify systemic issues in addressing the needs of older
Victorians who have a mental illness. Some of the issues covered in the reporting period were:
• the implications of a proposal to raise the eligibility age for aged persons mental health services
to 70 years
• de-gazettal of aged persons residential care facilities
• seclusion and restraint in aged persons mental health
• reportable deaths
• revised ECT manual
• protocol between mental health and aged care assessment services
• administration of medication for patients suffering from dementia
• memorandum of understanding between mental health services and the Royal District
Nursing Service
• advanced training in the psychiatry of old age
• the review of the Mental Health Act
• the Mental Health Reform Strategy 2009–2019.

28 Chief Psychiatrist’s annual report 2008–09
5.1.3 Statewide inpatient unit managers forums
Unit managers have a key role in establishing and supporting quality practice in inpatient mental
health services. The office continued to convene regular forums with inpatient unit managers from
around the state to discuss common issues.
Topics discussed at the Inpatient Unit Managers Clinical Practice Standards Forum included:
• clinical guidelines under development
• seclusion and restraint best practice presentations and updates on the Beacon and Creating
Safety projects
• sexual safety in inpatient units
• managing consumers with a borderline personality disorder in inpatient care
• smoking in inpatient units
• the review of the Mental Health Act.
Topics discussed at the Aged Persons Mental Health Residential Services Nurse Unit Managers
Forum included:
• comprehensive care assessments
• nursing leadership
• risk management
• accreditation
• regulatory frameworks.
These forums facilitate information sharing, foster best practice and innovation and help unit
managers to assume a leadership role within their local service.
5.1.4 Eating disorder services
The Chief Psychiatrist regularly meets with the statewide Centre for Excellence in Eating
Disorders (CEED) and the three specialist adult eating disorder inpatient units. The purpose
of these meetings is to:
• improve the quality of clinical care for people experiencing eating disorders across public mental
health and specialist services
• improve clinical pathways to specialist tertiary services for people with eating disorders
• support specialist tertiary eating disorder services to provide expert clinical care for people with
eating disorders
• facilitate resolution around complex issues relating to eating disorder clinical service provision.

Chief Psychiatrist’s annual report 2008–09 29
These meetings also provide a venue to identify other concerns that impact on the clinical care
for people with eating disorders that the Chief Psychiatrist may pursue through other avenues.
Key issues discussed in 2008-09 included:
• service access
• models of care and models of service for consumers with eating disorders
• dealing with co-morbidity (for example, a concurrent personality disorder, or substance abuse)
• common referral pathways and the role of triage
• care coordination (including medical care and linkages with paediatrics and child and adolescent
mental health services)
• the changing role of CEED
• changes in the client profile: younger persons presenting with more acute problems and with an
increase in the presentation of males.
5.1.5 Working with families and carers
The office has frequent contact with families and carers through telephone calls and letters, as
evidenced by the number of contacts made during the reporting period. The Chief Psychiatrist
recognises the important role of carers and the difficulties they can face in supporting their relative
and getting their concerns heard by services and clinicians. Through these contacts, the office
endeavours to support and guide carers in their interactions with service providers, and also draw
the attention of service directors and clinicians to the need for continuing effort in improving carer
engagement in the treatment and care process wherever possible.
The Chief Psychiatrist guideline on working together with families and carers can be found at
www.health.vic.gov.au/mentalhealth/cpg/families
5.2 Consumers with complex needs
An increasing number of consumers have particularly complex service needs that exceed the
capacity of a single service and require the coordinated effort of a number of agencies. Such
individuals generally suffer severe mental illness or personality disorder complicated by substance
abuse and/or intellectual impairment. A common feature is a level of behavioural disturbance that
presents significant risk to the person themselves, the community and staff working with them.
The Chief Psychiatrist provides an important leadership and coordinating role in bringing together
the various services and service elements to achieve an appropriate service system response and
support services in managing the risks. In doing so, the Chief Psychiatrist’s office works closely with
the Multiple and Complex Needs Initiative (MACNI) in the Department of Human Services, Disability
Services, Forensicare and with Spectrum, the statewide personality disorder service, to ensure good
communication across services and a coordinated effort in caring for shared high-needs clients.

30 Chief Psychiatrist’s annual report 2008–09
During the reporting period the Chief Psychiatrist and advisers convened or attended a number
of case conferences concerning clients with complex needs. Such requests have become more
frequent over recent years as services look centrally for assistance and direction in responding
to individuals with exceptional needs and risk issues. In particular there has been an increase in
requests for input with high-risk adolescents and individuals with mental illness and intellectual
disability. Case conferences may be held at the treating service or utilise teleconferencing. In
addition to the Chief Psychiatrist and senior clinicians from the treating services, such meetings
often involve those from other areas of Departmental responsibility such as disability services or
child protection, and the non-government sector.
5.3 Homicides and critical incidents
The Chief Psychiatrist is notified of critical incidents such as alleged homicides where the victim
or the perpetrator is a client of mental health services or believed to have a mental illness, serious
assaults, or a forensic patient absconding. The Chief Psychiatrist will gather relevant information
and provide briefings as required to keep the Minister for Mental Health and Secretary informed.
Most critical incidents of this kind will also be investigated by other agencies such as the Coroner or
Victoria Police. The Chief Psychiatrist arranges for the relevant service to provide a detailed report
regarding the care and treatment provided to those involved in a critical incident, and the response
of the service following the incident.

Chief Psychiatrist’s annual report 2008–09 31
6 Improving service quality
The Office of the Chief Psychiatrist undertakes a range of ongoing and time-limited activities to
monitor and promote continuous improvement in clinical standards across the mental health
service system, in addition to responding to identified concerns or problems. Improved service
quality leads to improved consumer outcomes.
6.1 Quality Assurance Committee
The Chief Psychiatrist chairs the Quality Assurance Committee (QAC), which was established under
section 106AC of the Mental Health Act and proclaimed a consultative council under the Health
Act 1958. The function of the QAC is to assist the Chief Psychiatrist in overseeing and monitoring
standards of treatment and care in Victorian public mental health services. The QAC meets
quarterly and membership consists of senior psychiatrists and mental health clinicians from across
the clinical mental health service system. Members are appointed as authorised officers under
the Mental Health Act for their work with the QAC and are subject to the confidentiality provisions
relating to authorised officers and consultative councils.
Membership of the QAC in 2008–09 is provided in the appendix. Further information about the QAC
is available at www.health.vic.gov.au/chiefpsychiatrist/qac.htm
The following key activities were undertaken by the QAC in 2008–09:
• The QAC reviewed sentinel events referred from the department’s Sentinel Event Program. 13
Sentinel events referred to the Chief Psychiatrist are de-identified (by patient and by service) and
include suicide (and near-miss suicide) in an inpatient unit (general hospital or specialist mental
health unit) and any other catastrophic event relating to a mental health consumer in an inpatient
service. The Chief Psychiatrist provides advice on any service system and quality issues arising
from these reviews to the Sentinel Event Program which, in turn, provides feedback to the relevant
services. During the reporting period 15 sentinel events were reviewed by QAC.
• The QAC provided joint oversight together with the Victorian Quality Council of the Creating
Safety: Addressing Restraint and Seclusion Practices project and its activities during the
reporting period (see 6.1.1)
• The QAC reviewed data reports about statutory functions and thematic summaries from coronial
reports 14 .
• The ECT subcommittee of the Quality Assurance Committee continued to meet in 2008–09. The
sub-committee monitors ECT practice, oversees ECT training and in January 2009 produced the
revised Electroconvulsive therapy manual. Licensing, legal requirements and clinical guidelines.
In 2009–10 the QAC is expected to auspice a new round of clinical reviews of public mental health
services.
6.1.1 Creating Safety: Addressing Restraint and Seclusion Practices
The Creating Safety project was launched in 2007–08 as a partnership initiative of the Chief
Psychiatrist, the Quality Assurance Committee and the Victorian Quality Council. The project
aimed to strengthen and support safety in acute mental health services using an evidence-based
13 Further information on the Sentinel Event Program can be found at
www.health.vic.gov.au/clinrisk/sentinel/ser.htm
14 These summaries an be accessed online at www.health.vic.gov.au/chiefpsychiatrist/corep

32 Chief Psychiatrist’s annual report 2008–09
approach. The project focused initially on the largest inpatient service component — adult acute
inpatient units — and will over time be extended to child and youth and aged persons mental health
services. One of the project objectives is to safely reduce and, wherever possible, eliminate the use
of restraint and seclusion.
The project had two key elements. The first was the development, implementation and evaluation
of a training and education framework using a prevention and early intervention model. This
commenced in 2007. A training and education program was rolled out across the state, with 585
mental health service staff completing the training. The purpose of the training was to increase
awareness of issues regarding the use of restraint and seclusion and to support practice change
while ensuring that practice complied with legislation and demonstrated adherence to guidelines.
The second component was the establishment of project sites in both rural and metropolitan
locations. Six adult acute inpatient units were selected through an expression of interest process.
These pilot sites were required to identify enablers and barriers to the reduction of seclusion and
restraint and to develop and implement seclusion and restraint reduction plans. The project ran
from January to September 2008 at these sites.
Key findings from the Creating Safety project include:
• reducing seclusion and restraint requires clinical leadership and organisational support
• it requires the involvement of all staff — not just nursing staff
• systems improvement needs to be underpinned by rigorous monitoring and review processes
• the experience of consumers and carers is fundamental to informing and evaluating practice
and should be incorporated systematically
• an appropriate physical environment and a supportive therapeutic milieu are integral strands
of a reduction strategy
• good practice needs to be sustained by a prevention and early intervention approach which
includes training in appropriate practice standards when restraint and seclusion are used
• practice change requires a sustained effort.
The Creating Safety project has demonstrated that the use of restraint and seclusion can be
reduced safely and effectively through the use of multiple strategies, including organisational
and clinical leadership; staff education; enhancing the physical and therapeutic environment;
monitoring and data analysis; active involvement of consumers as partners in care; and
identification of alternatives to restraint and seclusion.
The final report for the Creating Safety project is currently being developed and will include learning
from the project, tools and resources, and a training and education program template. The report
will be published and uploaded to the websites of the Chief Psychiatrist and the Victorian Quality
Council. It aims to provide a platform that public mental health services can use to create their own
restraint and seclusion reduction plans and initiate local practice improvements.
Beacon national demonstration project
Four inpatient units at Thomas Embling Hospital and the acute inpatient unit at Peninsula Health
participated as ‘Beacon’ sites in the national demonstration project for the reduction of restraint
and seclusion. These sites acted as centres of excellence in the reduction of restraint and

Chief Psychiatrist’s annual report 2008–09 33
seclusion. While the state and national projects formally concluded in 2008, these initiatives are
continuing at service level. A senior clinical adviser from the office managed the contract for the
Beacon demonstration sites for Victoria and also participated in the development of a suite of
documentation and guidelines as part of the national work on reducing restraint and seclusion.
6.2 Clinical guidelines
The Chief Psychiatrist issues clinical guidelines as needed on appropriate standards of practice
and service delivery in a range of areas. A guideline may be initiated by a change in legislation to
assist services and clinicians to understand the clinical application of the change. At other times a
guideline may be developed in response to an identified area of practice to establish standards and
promote more consistent practice as part of quality improvement.
During 2008–09, the Chief Psychiatrist produced a new Electroconvulsive therapy manual to reflect
changes in the law and clarify aspects of practice. In addition, a new Chief Psychiatrist guideline
was issued on restricted involuntary treatment orders and restricted community treatment orders.
Services are required to incorporate these standards and guidelines into their local policy and
procedures as a condition of their funding. Copies of all current Chief Psychiatrist guidelines are
available on the Department of Health website at www.health.vic.gov.au/mentalhealth.
Guidelines under development in 2008–09 included:
• Promoting sexual safety, responding to sexual activity, and managing allegations of sexual assault
in adult acute inpatient units
• Treatment plans under the Mental Health Act
• Inpatient leave of absence
• Reportable deaths.
6.3 Education and training
The Chief Psychiatrist’s office has a broad education and training role in informing mental health
service clinicians about the clinical application of the Act and acceptable practice standards. This
occurs through formal training sessions, often in response to a specific request from a mental
health service for input in a particular area, or more informally through the frequent interactions with
mental health service clinicians when they contact the office with a query, or when discussing a
complaint.
In 2008–09, the Chief Psychiatrist and clinical advisers delivered a range of presentations and
lectures on the Mental Health Act, legal and ethical issues in mental health service delivery and the
role of the Office of the Chief Psychiatrist.
Much of the service-based education is provided through the Education and Training Clusters 15 . The
Chief Psychiatrist regularly contributes to the training calendars of the clusters, as well as contributing
to specific training programs such as those provided by Mindful for child and adolescent psychiatry
trainees, or sessions provided for external agencies such as the Community Visitors Program. In
addition, the Chief Psychiatrist hosted the first annual ECT Training Providers Forum in 2008.
15 Victoria has three education and training clusters — consortia of mental health services that cover metropolitan
and rural areas, providing training and regional coordination to foster more consistent practice.

34 Chief Psychiatrist’s annual report 2008–09
7 Working with the department and other stakeholders
The Chief Psychiatrist and staff from the office work closely with colleagues in the Departments of
Health and Human Services, particularly the Mental Health, Drugs and Regions (MHDR) Division.
The Chief Psychiatrist is involved in various policy, process and operational matters relating to
mental health service delivery, where the office’s interface with service providers and service users
can bring a first hand perspective to the issues being considered. The Chief Psychiatrist and staff
are also involved in a number of departmental and interdepartmental committees.
Liaison also occurs with a range of government, non-government and advocacy bodies including
the Public Advocate, Health Services Commissioner, the Coroner, Mental Health Review Board,
the Ombudsman and the Department of Justice on matters of common interest and in response to
specific issues as they arise.
Some key areas of involvement during the reporting period have also been with the Office of the
Senior Practitioner in jointly seeking to improve outcomes for dual disability consumers 16 who come
to the attention of either office, and with the Multiple and Complex Needs Panel on care plans for
complex clients.
7.1 Mental Health Triage Project
In 2007 the Chief Psychiatrist led the development of a draft mental health triage scale and
guidelines in consultation with the MHDR Division’s Mental Health Triage Scale Advisory
Committee, which comprised consumer and carer representatives, senior clinical experts from the
mental health sector and divisional staff.
The scale is a rating system that guides clinicians in classifying triage contacts according to level
of urgency and the response required by mental health and other services. The purpose of the
scale is to promote a more consistent and clinically appropriate response to consumers, carers and
referrers seeking access to mental health services, and aid data collection about service access,
utilisation and demand.
Throughout 2008 the scale was piloted at 13 mental health services across the state, supported
by a training program including an e-learning component. The scale and the training program
have been formally evaluated and the findings used to inform further refinement of the scale and
guidelines. It is anticipated that the triage scale will be introduced in all Victorian area mental health
services in 2010.
The draft scale and guidelines, and further information about the project, can be found at
www.health.vic.gov.au/mentalhealth/triage.
7.2 Review of secure extended care services
There has been a growing demand for secure extended care unit (SECU) beds over recent years,
particularly for younger men with a dual diagnosis whose associated drug and alcohol issues places
them or the community at risk. Victoria has an acknowledged shortage of secure extended care
beds in both the general and forensic sectors. The Chief Psychiatrist regularly receives requests
from mental health services to facilitate access to such beds. The frequency of these requests is
increasing and metropolitan and rural units all report long waiting lists.
16 People with an intellectual disability and mental illness.

Chief Psychiatrist’s annual report 2008–09 35
In 2007–08 the division commenced a project to review the operation of SECU services. This
project has examined issues of access, throughput, and alternative models for meeting the needs
of this client group in the short, medium and longer term. The Chief Psychiatrist has chaired the
divisional working group overseeing the project and addressing related clinical practice issues.
The report of the working party is expected to be finalised in 2009–10. In the meantime, the Chief
Psychiatrist will continue to respond to requests for a SECU bed on a case-by-case basis. Providing
a wider range of bed-based and community options that are well connected with both clinical and
psychosocial rehabilitation services is also one of the goals of the Mental Health Reform Strategy 17 .
7.3 Response to the Victorian bushfires
The summer of 2008–2009 was accompanied by heartache and tragedy following the most
destructive and severe bushfires experienced for well over a decade. The then Department of Human
Services led the psychosocial response during the acute phase and in the aftermath of the fires. The
Office of the Chief Psychiatrist, and especially the Deputy Chief Psychiatrist, Child and Youth Mental
Health, contributed advice to those developing the psychosocial response and made a number of
site visits to support and advise those providing direct support in the affected communities.
7.4 Gender safety
In 2007 the Mental Health, Drugs and Regions Division established the Improving Gender Sensitivity
and Safety in Acute Mental Health Inpatient Units project to examine practices relating to the safety
and privacy needs of women admitted to these units. The Chief Psychiatrist was a member of the
advisory committee overseeing the project.
In 2008–09 staff from the office worked with the Senior Nurse Adviser and the Service Improvement
Unit on the development of a Chief Psychiatrist guideline on promoting sexual safety, responding to
sexual activity, and managing allegations of sexual assault in adult acute inpatient units.
7.5 Cross-border and interstate apprehension orders
Victoria has agreements with New South Wales and South Australia covering the interstate
treatment, transfer and apprehension of involuntary patients 18 . In 2008–09 the cross-border
agreement with NSW had to be reviewed as a result of changes to mental health legislation in NSW.
This review was undertaken by the division’s Legal and Forensic Policy Unit in collaboration with the
Chief Psychiatrist.
The Chief Psychiatrist and a senior clinical adviser from the office participated on the steering
committee, took part in cross-border consultations with the sector and provided advice on the
implications of the proposed changes for clinical practice. It is expected that the division will issue
an updated program management circular in 2009–10.
17 See Because Mental Health Matters. Victorian Mental Health Reform Strategy 2009-2019, pp. 96-97.
18 These cross-border agreements can be found at: www.health.vic.gov.au/mentalhealth/crossborder

36 Chief Psychiatrist’s annual report 2008–09
7.6 Contributions to reviews
In 2008–09 staff from the office contributed to the review of the Mental Health Act and participated
as steering committee members on the reviews of the statewide child inpatient unit and acute
mental health inpatient services for adolescents in Victoria.
7.7 Freedom of information
The Freedom of Information (FOI) unit of the Department of Health receives a variety of requests for
information under the Freedom of Information Act 1982 (Vic). Where these records pertain to individual
client records held by the department, the Chief Psychiatrist is required to provide an assessment and
advice to the FOI unit on the recommended circumstances of release of the documents, taking into
consideration the potential impact on the consumer or others of such release.
During the reporting period, the Office of the Chief Psychiatrist assisted the FOI unit in providing
recommendations regarding release of departmental client records and also provided documents
under the FOI Act in relation to nine separate FOI requests (compared to 17 in 2007–08).

Chief Psychiatrist’s annual report 2008–09 37
8 Forensic mental health
Forensic mental health services are provided to mentally ill offenders or to those consumers who
present a serious risk of offending behaviour. Courts can make specified orders when determining
the most appropriate disposition for a person where mental illness has played a role in the
offending behaviour. Instead of a sentence, or by way of a sentence, a court may direct a person to
receive treatment as an involuntary patient in an approved mental health service.
In Victoria, forensic mental health services are provided through the Victorian Institute of Forensic
Mental Health (Forensicare) and are located within the prison system, in a specialist forensic
mental health hospital (Thomas Embling Hospital) and the community-based forensic mental health
service in Clifton Hill. The Chief Psychiatrist is a member of the external advisory group providing
support to a large research program carried out under the auspices of Forensicare.
The Chief Psychiatrist has a range of responsibilities for mentally ill offenders under the Mental Health
Act and the Crimes (Mental Impairment and Unfitness to be Tried) Act.
8.1 Restricted involuntary treatment orders, hospital orders
and restricted community treatment orders
The Sentencing and Mental Health Acts (Amendment) Act made significant changes to the
provisions governing hospital orders, hospital security orders and restricted community treatment
orders, effective from 1 October 2006. Essentially the amendments replaced hospital orders with
a new order known as a restricted involuntary treatment order (RITO), which can only be made
for a maximum of two years for people found guilty of a non-serious offence. Special transition
arrangements were made for those patients on existing hospital orders at 1 October 2006, as these
orders were deemed to expire on 1 October 2008.
When the court makes a person subject to a RITO, the person must be taken to and detained in a
mental health service as an inpatient. When the person’s condition has improved to the extent that
they can be treated and managed safely in the community, the authorised psychiatrist may make a
restricted community treatment order (RCTO) enabling the person to continue their treatment in the
community. The authorised psychiatrist must notify the Chief Psychiatrist of the making of an RCTO 19 .
In 2008–09, 10 RITOs and 12 RCTOs were made under the new provisions (compared to 19 RITOs
and 21 RCTOs in 2007–08).
8.2 Security patients
Security patients are those detained in an approved mental health service for treatment of
their mental illness, either on a court order under the Sentencing Act (s.93(1)(e)) as part of their
sentence, or by order of the Secretary of the Department of Justice under the Mental Health Act
(s.16). In Victoria, such patients receive treatment and care for their mental illness in Thomas
Embling Hospital (a secure specialist forensic mental health facility) until it is appropriate for them
to be returned to prison or to the community if they have reached the end of their sentence.
19 For further information see program management circulars: Sentencing and Mental Health Acts (Amendment)
Act 2005: Summary of key amendments, Changes to hospital orders under the Sentencing Act 1991 and Restricted
involuntary treatment orders and restricted community treatment orders.

38 Chief Psychiatrist’s annual report 2008–09
The Chief Psychiatrist is responsible for approving a security patient’s discharge back to prison
if satisfied that the criteria for being a security patient are no longer met. In doing so, the Chief
Psychiatrist must have regard primarily to the person’s current mental condition and consider their
medical and psychiatric history and social circumstances. People requiring continuing involuntary
treatment at the expiry of their sentence may receive treatment under the standard provisions of
the Act.
The Secretary of the Department of Justice must consult with the Chief Psychiatrist when allowing
a security patient to be absent from an approved mental health service (in which they are detained
for a period not exceeding six months). The Secretary must be satisfied that the leave will not
seriously endanger the safety of the public or the safety of the consumer.
The Chief Psychiatrist has the power to authorise special leave for security patients for specifically
defined purposes, usually medical treatment or to attend court. Special leave for security patients
cannot exceed seven days in the case of medical treatment or 24 hours in any other case. The
Chief Psychiatrist is required to immediately notify the Secretary of the Department of Justice when
approving special leave or discharging a person from security patient status.
8.3 Forensic Leave Panel
The Forensic Leave Panel is an independent statutory body established under the Crimes (Mental
Impairment and Unfitness to be Tried) Act (CMIA), to consider applications for leave from persons
subject to custodial supervision orders. The Chief Psychiatrist (or delegate) is a member of the panel
and has power under the CMIA to suspend leave for forensic patients at any time if satisfied that the
safety of the person or members of the public is at risk of serious danger.
The Forensic Leave Panel must submit a yearly report to the Attorney-General that includes the
number and type of leave applications made, leave refused and leave suspended. More information
can be found in the Forensic Leave Panel’s annual report 20 .
Staff from the Chief Psychiatrist’s office participated with the Community Forensic Mental Health
Service in a statewide training program to launch the new program management circular on noncustodial
supervision orders and inform mental health service clinicians on their legislative and
clinical obligations in managing persons under the CMIA.
20 The annual reports of the Forensic Leave Panel are available online at
www.health.vic.gov.au/mentalhealth/forensic.

Chief Psychiatrist’s annual report 2008–09 39
Appendix: 2008–09 membership
of the Quality Assurance Committee
Professor Kuruvilla George 21
Chief Psychiatrist
Mental Health, Drugs and Regions Division
Department of Health
Dr Ruth Vine 22
Chief Psychiatrist
Mental Health, Drugs and Regions Division
Department of Health
Associate Professor Ravi Bhat
Director of Psychiatry
Goulburn Valley Area Mental Health Service
Dr Peter Burnett
Director, Clinical Governance
North West Mental Health
Dr Tom Callaly
Chief of Services
Community and Mental Health Program,
Barwon Health
Ms Karlyn Chettleburgh
General Manager, Inpatient Services
Thomas Embling Hospital
Dr Paul Denborough
Director, Child and Adolescent
Mental Health Service
Alfred Health
Mr Peter Kelly
Operations Director, Mental Health Services
Melbourne Health
Ms Sandra Keppich-Arnold
Associate Director of Nursing
Alfred Psychiatry
Ms Bee Mitchell-Dawson
Senior Clinical Adviser
Mental Health, Drugs and Regions Division
Department of Health
Associate Professor Richard Newton
Medical Director, Mental Health
Austin Health
Professor Daniel O’Connor
Director of Clinical Services
Aged Persons Mental Health, Southern Health
Dr Bruce Osborne
Clinical Director
Latrobe Regional Mental Health Service
Dr Bob Salo
Director, Child and Adolescent Mental
Health Services
Royal Children’s Hospital
Dr Dean Stevenson
Director, Clinical Services
Werribee Mercy Mental Health Program
Ms Kate Thwaites
Clinical Adviser
Mental Health, Drugs and Regions Division
Department of Health
21 Chief Psychiatrist from October 2007 to May 2009
22 Chief Psychiatrist from May 2009