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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527
   
Great things are not done by impulse, but by a series of small things brought together.
Vincent van Gogh
   

FAQ  


Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527
   

Word Cloud  


Strict Standards: Non-static method modJoesWordCloudHelper::getModuleContent() should not be called statically in /home/billbmn/public_html/wcmi1/modules/mod_joeswordcloud/mod_joeswordcloud.php on line 18

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/modules/mod_joeswordcloud/helper.php on line 229
   

Latest Additions  


Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 73

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527
   

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 212

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 1527

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/plugins/content/joocomments/joocomments.php on line 21

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/plugins/system/joomsef/joomsef.php on line 473

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 69

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/administrator/components/com_sef/classes/seftools.php on line 949

Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.ext.php on line 68

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Strict Standards: Only variables should be assigned by reference in /home/billbmn/public_html/wcmi1/components/com_sef/sef.router.php on line 115

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Strict Standards: Only variables should be passed by reference in /home/billbmn/public_html/wcmi1/components/com_sef/joomsef.php on line 378

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The Age - Dying in the Arms of the State

Deaths in Care or 'Adverse Events '?

Details


Deaths in Care or 'Adverse Events '?

The Age Newspaper here in Victoria has highlighted two tragic issues.

First, the deaths of patients in psychiatric care and secondly what seem like efforts taken by those organisations to shroud those deaths in secrecy.

"Each case involves allegations that serious failings by senior mental health staff may have contributed towards their unexpected deaths. Evidence also suggests that the health services involved allegedly covered up or failed to collect important information about the deaths, possibly preventing a proper examination of their cause."

The events that gave rise to these reports are terrible, and the loss to families and to us all is awful. But as the Age points out, it seems such things have been happening for years.

They have been unremarked as much more than a circular each year from the Office of the Chief Psychiatrist; tragic individually but not intrinsically significant or meaningful on a wider level; a result of the level of illness of the people in the system, just 'something that happens', the price of doing business in the "mental health area ............one of the most difficult for health professionals".

As the article and much other evidence shows It's not real easy for families or patients either.

The Age for the first time is putting a human face on these 'statistics', is asking if there are systemic, cultural, institutional preventable reasons for these deaths Continued


Deaths in mental health facilities: unexpected, unnatural and violent

Richard Baker and Nick McKenzie

September 3, 2011

http://www.theage.com.au/victoria/deaths-in-mental-health-facilities-unexpected-unnatural-and-violent-20110902-1jqdg.html

Lucy Mizzi and her daughter Sarah (right) at the Preston cemetery where Lucy's brother Anthony Travaglini is buried. Photo: Jason South

THIRTY-SIX people died unexpected, unnatural or violent deaths in Victorian mental health facilities between 2008 and 2010, Coroners Court files reveal.

Data released to The Saturday Age by the Coroner's Prevention Unit reveals 119 of the 502 coronial inquests held in Victoria between 2008 and 2010 involved people with diagnosed mental illnesses.

Of those 119 mental health coronial cases, almost a third related to the deaths of patients while they were being treated at state-run and private mental health facilities. Other figures from the Department of Health show 975 people under the care of Victoria's mental health system have died unnatural, unexpected or violent deaths between 2006 and 2010.

These include mental health patients under the care of the state who committed suicide outside psychiatric facilities, as well as those who died in car accidents and house fires or drowned. But they also include dozens of patients who died in Victorian psychiatric wards.

The Saturday Age today publishes an investigation into the deaths of three men who died in state-run psychiatric wards across Melbourne between 2007 and 2009: Adam White, 31, Anthony Travaglini, 40, and Jeffery Hartwig, 43.

Each case involves allegations that serious failings by senior mental health staff may have contributed towards their unexpected deaths. Evidence also suggests that the health services involved allegedly covered up or failed to collect important information about the deaths, possibly preventing a proper examination of their cause.

Mr White's death was the subject of a coronial inquest this year but a finding has yet to be made. The deaths of Mr Travaglini and Mr Hartwig are to be investigated by a coroner at a later date.

Southern Health, the health service responsible for the care of Mr Hartwig and Mr White care, this week complained to the Coroner's Court after receiving questions from The Saturday Age about their deaths. A suppression order was made by coroner John Olle preventing the newspaper from publishing important information about Mr Hartwig's death. Despite this, the paper is determined to report as much as it can about these deaths.

Our investigation found:

■ Mr Travaglini, who died in September 2008 at Eastern Health's Upton House psychiatric hospital in Box Hill, was killed by a combination of powerful anti-psychotic medications given to him by staff, according to a Victorian government pathologist. Staff and patients aware of the circumstances of his death say the 40-year-old was pleading not to be given more drugs on the night he died. Staff and patients also allege there was an attempt to conceal information about the circumstances of his death from his family.

■ Mr Hartwig died at the Monash Medical Centre in December 2009 after he went into a coma following a suspected overdose of illicit drugs supplied by unknown visitors. His family says the hospital's psychiatric ward kept no visitor log nor did it supervise visits to patients. Police sources say the hospital's legal department interfered with their investigation and ordered staff not to speak about the circumstances of Mr Hartwig's death.

■ Mr White's 2007 death at Dandenong Hospital's psychiatric ward during a struggle with security guards was the subject of a recent inquest. A finding has yet to be made, but evidence to the inquest suggests Mr White was asphyxiated while being held face down by security staff. A witness told the inquest that Mr White apparently yelled ''I give up'', but security did not ease off. He died soon after.

The circumstances of the men's deaths and the treatment of their families raise questions about whether there is a culture of cover-up in the Victorian mental health system. The families have complained of a lack of answers from health services responsible for the care of their loved ones.

Eastern Health declined to comment, citing the coming inquest into Mr Travaglini's death.

In addition to asking that details of Mr Hartwig and Mr White's deaths be suppressed, Southern Health said it was ''committed to patient-centred care and constant improvement in regards to the quality of service we provide to our patients''.

Health Department statistics show that 239 people, 162 of them men, under the care of Victoria's mental health system died unexpected, unnatural or violent deaths in 2009-10.

Melbourne Health and Eastern Health had the highest rates of unexpected, unnatural or violent deaths, with 44 and 31 respectively.

In 2008-09, there were 302 such deaths. In 2007-08 there were 205 and in 2006-07 there were 229.

Victoria's chief psychiatrist, Ruth Vine, admitted the performance of Victoria's mental health system could improve.

Dr Vine said she could not comment on the specific issues identified in the three deaths.

But she said the mental health area was one of the most difficult for health professionals.

''I don't wish to be defensive or an apologist because I'd be the first to admit that our care provided is not perfect all the time,'' Dr Vine said.

''But it is difficult to manage fairly large, fairly aggressive men and I think it is the case in some of these [deaths] that there was a degree of physical unwellness underlying.''

Dr Vine said Victoria had taken steps in recent years to improve care given to mental health patients.



Read more: http://www.theage.com.au/victoria/deaths-in-mental-health-facilities-unexpected-unnatural-and-violent-20110902-1jqdg.html#ixzz1X9G2FLFF

 


Dying in the arms of the state

Richard Baker and Nick McKenzie

September 3, 2011

Tracey Downward and Julie Nestic hold a photo of their brother, Adam White. Photo: Jason South

Thirty-six people died unnatural, unexpected or violent deaths in Victoria's mental health facilities between 2008 and 2010. Their deaths drew little, if any, public attention, but each has a story behind it, and a grieving family searching for answers. Today The Saturday Age tells three of those stories - of sick men who died in troubling circumstances in the care of the state.

ANTHONY TRAVAGLINI, 40…………

Died September 8, 2008, at Upton House psychiatric hospital, Box Hill…………

JEFFERY HARTWIG, 43
Died December 15, 2009, at Monash Medical Centre…………

ADAM WHITE, 31
Died April 20, 2007, at Dandenong Hospital psychiatric unit

ADAM White had been a patient at Dandenong Hospital's Banksia psychiatric ward for just two days. The schizo-affective disorder that had plagued him periodically since the mid-1990s had once again taken grip in April 2007. White, 31, knew he was sick and so did his family. On April 17 he went to Maroondah Hospital voluntarily to seek treatment in its psychiatric ward. It was a significant step as it was the first time he had voluntarily sought care for his illness, but he was, at least, familiar with Maroondah's psychiatric ward, where had been cared for in the past, and which was close to where many of his family lived.

On this occasion, however, he was told no beds were available. After waiting hours in Maroondah's emergency ward, White was transferred by ambulance to Dandenong's Banksia ward. About 11pm on April 19 he was observed by hospital staff pacing in the courtyard. Although he showed signs of being agitated and psychotic, he was given no medication and was eventually settled back in bed.

He woke again hours later and approached the nursing station. This time, he was noted by staff as singing in an odd way and acting strangely.

It was at about this point, say family members, that a situation that might have been defused, instead escalated.

In fact, one nurse did offer him a cup of tea to try and help him settle, before another told him he could not eat or drink as he was fasting for a blood test. According to his sister, Julie Nestic, White protested and asked to have his blood taken straight away, so that he could get something to eat. To defuse the situation, a nurse said she would take his blood, and called security staff to escort him to the treatment room. But there was another hold-up, as the nurse did not have the proper paperwork.

So White was left to sit in the treatment room with hospital security staff watching him from outside the room. When the nurse came back, she announced that it had been decided that his blood would not be taken after all.

White was tired and hungry and ill. He reacted by pulling out a drawer from a cabinet next to where he was sitting and letting it fall to the floor.

It was now about 4am and the three nurses and two security guards on duty overnight had to prepare to unlock the hospital for the start of a new day and the arrival of a fresh shift. In his agitated state, Adam presented a problem. Staff decided to put him temporarily in the seclusion room.

There are conflicting statements from staff about whether White was going to be locked in the seclusion room. Some staff are understood to have made statements claiming Adam was to have been left in ''open seclusion'', meaning the door would have been left unlocked and he would have had access to an external toilet. However, a nurse has said she was bringing toilet paper, a bed pan and water to the room, which suggests the door was to be locked.

In any event, on his way to the seclusion room, White asked for his toothbrush - and was told no. At this point, it seems that the frustration and confusion of the previous hours spilled over. White reacted strongly to being told he could not brush his teeth and a struggle broke out between him and the two male security guards. White, described by his family as a big man, was held in a prone position on the floor. The nurse was elsewhere. When she returned it was too late.

Julie Nestic, who has attended this year's coronial inquest into his death, says it has been stated that during the struggle, her brother yelled out ''I give up'', to no avail, before going still. Nestic says one of the security guards reportedly asked the other, ''Is he playing possum?'' He was not.

White had died of asphyxiation after being held in a position in which he could not properly breathe.

White's oldest sister, Tracey Downward, 43, was preparing her young children for school when she learned that her brother was dead. She remembered the last time she had seen him at Maroondah Hospital's emergency department a few days earlier. She had wiped his face with a face washer and told him she loved him.

With Julie Nestic, she joined other family members at their parents' house and arranged to go to Dandenong Hospital together to view his body. The hospital knew they were coming and a staff member called one of the family on the way to ask them to delay their arrival as the police still had work to do. When they arrived, the family were led into a room where they were told the body had already been taken to the morgue. If they wanted to see him, they would have to go there.

The grieving family was appalled.



Read more: http://www.theage.com.au/victoria/dying-in-the-arms-of-the-state-20110902-1jqf5.html#ixzz1X9H6W8rA

 

 


Working on a better mental health system

Ruth Vine

September 5, 2011

OPINION

Comments 18

 

http://www.theage.com.au/opinion/society-and-culture/working-on-a-better-mental-health-system-20110904-1js5t.html

'There is a clear commitment to deliver improved care for those with the most complex needs.' Photo: Gabriele Charotte

Improved care for those with complex needs is one of the main goals.

The challenges facing mental health services are receiving considerable attention, including in The Age and The Saturday Age, reflecting greater community awareness and acceptance that illnesses such as depression and anxiety are common and treatable.

In Victoria, about 10 per cent of the state health budget is spent on mental health. While it is often reported that one in five will experience a mental illness during their lifetime, state-funded mental health services primarily respond to the much smaller number of people with severe illness such as schizophrenia or bipolar affective disorder and to people experiencing a crisis or acute episode.

Victoria's area-based mental health system was established in the 1990s to provide a range of community and bed-based clinical services. Victoria was ahead of other states in developing and supporting a system of care from early intervention to continuing care.

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Much has changed since the mid-'90s. Victoria now spends about $1 billion a year on mental health services. Demand has increased, meaning we need to develop more efficient and effective services.

 


http://www.theage.com.au/victoria/another-way-of-thinking-20110905-1ju4q.html

Another way of thinking

Richard Baker and Nick McKenzie

September 6, 2011

Cheryl Hipworth and her brother Gary. Photo: Jason South

Many of Victoria's psychiatric patients want more say about what is being done to them in the name of treatment.

CHERYL Hipworth has had a tough life. A violent father made her early years in Melbourne's western suburbs in the 1950s and 1960 the stuff of nightmares. She became pregnant in her teens only to have her babies taken away. In the 1980s, her beloved brother was murdered, and years later her son and then her mother took their own lives.

These events contributed to Ms Hipworth developing a serious mental illness, and for more than 20 years she has drifted in and out of Melbourne psychiatric institutions.

An ever-present community treatment order - the mechanism that allows Victoria's mental health system to treat ''involuntary patients'' in the community - meant Ms Hipworth has spent most of her time on the couch in her small St Kilda flat under the influence of a heavy dose of anti-psychotics.

''A chemical lobotomy'' is how Ms Hipworth, 62, described her state when visited by The Age. ''I believe the drugs have sent me mad.''

But at least Ms Hipworth was not alone, unlike the man she knew as Jack who lived in the flat beneath hers. He was also mentally unwell and subject to a community treatment order. He died alone last year, and his body lay undiscovered for five days, she says.

Ms Hipworth has the enduring support of her brother Gary, who has been determined to help his sister regain control of her life. Together they have made repeated attempts to convince a Victorian Mental Health Review Board to release her from her community treatment order and involuntary patient status.

In May last year, Ms Hipworth promised a three-member review panel that she would stick to her anti-depressant regime and seek counselling and home support to help with her recovery.

According to Gary Hipworth, the panel was impressed by his sister's presentation and commitment to manage her own rehabilitation. They ruled that the community treatment order remain but be reviewed again in three months.

At her next appearance last September, Ms Hipworth faced just one panel member. This member had no legal or psychiatric expertise, says Mr Hipworth, and sided with the doctor from the psychiatric clinic treating his sister, who had met her only days before.

''She was kept on the community treatment order despite the impression she had made back in May,'' Mr Hipworth says. ''But what chance did she have when two of the panel members were not even there and the doctor only knew Cheryl from her notes and not as a person?''

The pair felt the review system had failed them over all over again.

When The Age interviewed Ms Hipworth in May this year, she was preparing for another attempt to convince a Mental Health Review Board to release her from her involuntary patient status.

''There is nothing to lose,'' Mr Hipworth says. ''I'm not going to see my sister go down the tube because of what the state is doing to her. I want her to get justice.''

Ms Hipworth's story has much in common with those of thousands of other Victorians deemed too mentally unwell to have a say in their treatment.

The Age has interviewed several men and women with various psychiatric disorders who have been admitted to psychiatric wards as involuntary patients and later released under a community treatment order.

A common frustration for them is the model of care in Victoria that relies heavily on forced medication with often detrimental side effects, such as significant weight gain.

Involuntary mental patients are the only people in the entire medical system who cannot refuse treatment. Victoria is also the only state in Australia where involuntary mental health patients and their families have no right to appeal against a prescribed course of treatment.

Unlike New South Wales, Victoria has no independent medical tribunal to oversee the treatment of an involuntary patient. The Baillieu government is under pressure to give involuntary patients and their families a greater say in treatment plans at the completion of its long-awaited review of Victoria's Mental Health Act later this year.

Greg Oke, an advocate for the rights of the mentally ill and a former Eastern Health patient welfare officer, says Victoria's approach to treating psychiatric disorders breaches a fundamental human right - to determine your own medical treatment.

''Nobody can force a person with cancer to undergo chemotherapy against their wishes. But a person experiencing mental health issues can be forced against their will, without any explanation, to take a combination of psychiatric drugs with some extreme side effects and receive controversial treatments such as electro-convulsive therapy,'' he said

''Victoria needs to establish legislation consistent with the Victorian Charter of Human Rights that at the very least entitles these people the right to a fair hearing.''

Many psychiatric patients interviewed by The Age say they recognise the role anti-depressant and anti-psychotic drugs have in managing mental illness. But they believe not enough attention or funding is directed to other important areas such as counselling and home-support programs.

Some are angered by recent government decisions to direct more funding to drug-based treatment programs such as Professor Patrick McGorry's early-intervention model - where young people diagnosed at risk of developing a mental illness are prescribed drugs. ''It is not about being anti-psychiatry, it's about being critical of it,'' says Belinda Jane. ''My issue with the system is that it is based on medication and force.''

Ms Jane says she was sexually abused as a child and had suffered from a disassociative disorder ever since. At its worst, the disorder causes her to ''go blank'' and engage in dangerous behaviour, such as wandering the streets and even setting fire to her house.

Ms Jane does not doubt medication has its benefits, but warns against a one-size-fits-all approach.

''It is about putting all the therapies and all the services together in a unified way. There is no reason a person cannot be treated by medication in combination with counselling services and home-support programs. But that does not seem to be happening enough,'' she says.

In her case, Ms Jane says, she would like to see funding for massage therapy so she could learn what ''safe touch'' is after years of abuse. Like Ms Jane, several other mental health patients who spoke to The Age about their experiences suffered sexual abuse either as a child or, in some cases, after being admitted to state-run psychiatric facilities.

Amanda Thorburn was abused by a male family member when she was 15. Soon after this, she entered Victoria's mental health system where she was given large amounts of anti-psychotic medication and courses of electric shock therapy.

At Eastern Health's Upton House she was given 35 treatments of ECT, she says. ''They said I was in a bad patch of depression. I realised it was just to keep me quiet and to numb everything,'' she says.

Now in her mid-20s, Ms Thorburn experienced ''just about everything'' while inside various Victorian psychiatric wards. She was given the heaviest of tranquilisers and placed in a seclusion room for two days. She awoke to find she had wet herself, she says.

ON another occasion, Ms Thorburn says she was chained to a bed while water was poured down her throat to force her to swallow pills. The use of the shackles was not recorded in her file, she says.

Ms Thorburn's experiences were not all negative. She said she did meet some caring staff working in the mental health system.

''These people were the ones who asked how you were and gave you a sense you had a future. They were not always on the look-out for deficits in your character.

''But there were others in the system whose focus on negatives was overwhelming. You have got to have more of a message for a young person than simply saying 'you are going to be on medication for the rest of your life'.''

In 2009, Ms Thorburn was in despair. Diagnosed variously with schizophrenia and bi-polar disorder, her depression had deteriorated further, she says, after a massive weight gain caused by her medication.

She saw suicide as the only way to free herself. She planned the event and wrote goodbye letters.

Somehow she survived an eight-metre plunge from a bridge above railway tracks in Ringwood. But she broke both legs, fractured her pelvis, ruptured her spleen and her spinal chord was compressed.

Ten operations later her body has recovered as much as it can.

Amazingly, so has her state of mind. Ms Thorburn says she has weaned herself off medication and lost 50 kilograms. She is also finishing her VCE as a mature-age student and hopes to go to university.

By talking publicly about her experience, Ms Thorburn hopes she can inspire other people, particularly young women, to summon the courage to confront their own situations and search for the treatments they believe will work best for them.

''There is a stigma that prevents people from talking about mental health. But that is why I have chosen to talk about my situation because it shows that even though it is hard, you can get through it,'' she says.

Kate (who asked that her surname be withheld) says she was subject to sexual abuse as a patient in the Victorian mental health system. Kate was sexually assaulted 10 years ago inside a Melbourne psychiatric hospital. She was having a bath, and a female nurse was in the room to ensure she did not hurt herself. For some reason, the female nurse left and was replaced by a male staff member.

Later that day, she says, the same male nurse entered her room and forced himself on her. Kate told The Age she did not report the incident because she thought no one would believe her.

A decade of treatment later, Kate now has a senior job in Victoria's health care system.

She still feels strongly about the prevailing attitudes towards the mentally ill in Victoria and the lack of rights afforded to those deemed to unwell to choose their own course of treatment.

''The social prejudice in mental health is just so severe. You get totally judged by what you look like. One of the five questions used to define your status is, 'Does the person appear to be mentally unwell?''' she says.

''The operative word is 'appear'. I am a bit of a feminist and do not colour my hair or wear make-up. So I was described in my report as 'dishevelled'. Instantly I was on the back foot because of the way I looked.''

On May 27, Cheryl Hipworth again decided to stand up for herself by fronting the three-member Mental Health Review Board to request a release from her community treatment order.

Supported by her brother and mental health advocate Greg Oke, Ms Hipworth asked to read a three-page statement to the review board. The statement included evidence compiled with help from her brother that questioned the basis for her continued medication. This request was initially rejected. Matters looked even worse when her case manager argued that she should remain on her treatment order.

Fed up, Mr Hipworth stepped in and asked the review board why his sister had not been allowed to present her case. The meeting was adjourned and the review board members discussed Ms Hipworth's case in private.

When they returned they asked her if she had a mental illness. She answered: ''Depends how you define it.''

Ms Hipworth told the review board that she would continue to take her medication if released from her status as an involuntary patient. She also explained how her brother had arranged for a private outreach service to help her at home.

This time, the review panel decided in Ms Hipworth's favour. She was officially no longer one of Victoria's involuntary mental patients. For the first time in a long while she was given charge of her own destiny.

Since that day the change in Ms Hipworth has been remarkable. She appears in better physical condition and has more confidence in herself.

''The beauty of it is she has got her life back and I'm going to help make sure there is no slipping back,'' says Mr Hipworth.



Read more: http://www.theage.com.au/victoria/another-way-of-thinking-20110905-1ju4q.html#ixzz1X9GImFRk

 


State urged to act on 'shocking' death rates in mental care

Nick McKenzie and Richard Baker

September 5, 2011

http://www.theage.com.au/victoria/state-urged-to-act-on-shocking-death-rates-in-mental-care-20110904-1jsh1.html

More needs to be done to prevent unexpected, unnatural or violent deaths in the mental health system.

VICTORIA'S disabilities watchdog has called for urgent reforms to address the ''shocking'' number of people dying in the state's psychiatric facilities - 36 over two years - amid fresh revelations about the mistreatment of mentally ill people.

The Public Advocate, Colleen Pearce, says more needs to be done to prevent unexpected, unnatural or violent deaths in the mental health system - and to ensure grieving families and the public are told why such deaths are occurring, and at such a high rate.

Her call comes as an investigation by The Age has found that:

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■ The Brumby government was warned in 2010 that mentally ill people were dying as a result of ''unethical and illegal'' practices.

■ Peninsula Health chief Sherene Devanesen wrote in 2008 about three ''unexpected deaths'' in a mental health ward over a short period. She also wrote that ''some areas of practice and behaviour were not consistent with Peninsula Health values and … contemporary psychiatric practice.

■ Anthony Travaglini, 40, who died in a psychiatric ward in September 2008, was severely mistreated by ''very aggressive'' staff who repeatedly medicated him despite his deteriorating state, according to fresh claims.

These allegations are contained in a letter sent to the Department of Human Services by the director of the Mental Illness Awareness Council, Isabell Collins, who met staff and patients from Eastern Health's Upton House shortly after Mr Travaglini's death.

In her letter, Ms Collins said a patient had told her he had ''expressed concern to staff that Anthony did not look OK and suggested they take his observations, but they just gave him more drugs''.

A forensic pathologist has found Mr Travaglini's death was most likely caused by a combination of drugs in his system.

Mr Travaglini is one of three people who had an unexpected and unnatural death, and whose cases the The Saturday Agerevealed were linked to allegations of serious failings by senior mental health staff at state-run psychiatric wards in recent years.

Ms Collins told The Age that the existing system of oversight into the deaths of Victorians in state-run mental health facilities, or shortly after they are discharged, needs an overhaul.

Her views are supported by the Office of the Public Advocate - an independent statutory body created to protect the rights of disabled and other vulnerable people - which has called on Victoria's Chief Psychiatrist, Ruth Vine, to follow the lead of the Victorian Child Death Committee and make public more information about unexpected or unnatural deaths and associated systemic issues.

Dr Vine's past public reports contain minimal detail about the causes of deaths

and associated systemic issues.

Ms Pearce said discrepancies in figures released by various state agencies, along with the lack of detail about why the deaths were occurring in the system, had to be addressed.

''The community expects that people will be safe from harm in hospitals. The number of people dying while under the care of the mental health system is shocking. There needs to be urgent changes to tackle preventable deaths and improve mental health care. This must be a priority,'' said Ms Pearce.

Ms Pearce's call came in response to revelations in The Saturday Age that 36 people had died unexpected, unnatural or violent deaths inside mental health facilities between 2008 and 2010. The figures are based on files released by the Coroners Prevention Unit, which also reveal that 119, or nearly a quarter, of the 502 coronial inquests held in Victoria between 2008 and 2010 involved people with diagnosed mental illnesses.

Of those 119 mental health coronial cases, almost a third involved deaths of patients while they were being treated at state-run and private mental health facilities.

Ms Pearce said: ''The question for us is why? Why did they die, how could they die [in a mental health facility] and what can we do to prevent it? Families want answers … Why shouldn't families know why their loved ones have died and what did the system do to improve or address the problem?''

She has also called for far greater support for mental health patients before and after they are discharged, including access to appropriate housing and treatment for alcohol and drug dependencies. ''There is a huge campaign on the road toll. Why aren't the same resources put into saving these people?''

Among leaked mental health service documents obtained by The Age is an email by a senior psychiatrist from one of the state's busiest acute mental health units. It was sent in January 2010 to then community services minister Lisa Neville and states: ''You may already be aware that Eastern Health Adult Psychiatry Service has [among] the highest rate of unnatural deaths in the state. What you may not be aware of is the unethical and illegal practices that are resulting in such poor outcomes and the resignation of over 22 senior medical staff since the commencement of management there.

''I would like an audience with you to bring to your attention in confidence some of the practices that are causing such poor outcomes and suffering. I have tried to raise these issues locally but unfortunately been met with vicious attacks on my personal and professional reputation.''

The psychiatrist, who asked for his name to be withheld because he still works in the health system, said his concerns were never addressed.

The Age has also obtained emails written in 2009 by a member of Eastern Health's Community Advisory Committee, which was set up in 2001 to give community representatives input into the health services operations.

The emails show that efforts by a committee member to get information about problems in mental health wards were constantly thwarted.

''I'm seriously thinking of resigning from the Community Advisory Committee as it is too restrictive and I seem to keep getting into trouble for asking questions,'' one email states.

Greg Oke, who was employed for four years as an adviser to Eastern Health on ways to protect the rights of patients, said mental health facilities tended to adopt a ''custodial approach'' to mentally unwell people rather than an approach respecting people's dignity.

Mr Oke, who left Eastern Health in mid 2009, said: ''People using Victorian mental health services are being treated in a cruel, inhumane and degrading way. Their human rights are being degraded on a daily basis.''

With KATE HAGAN



Read more: http://www.theage.com.au/victoria/state-urged-to-act-on-shocking-death-rates-in-mental-care-20110904-1jsh1.html#ixzz1X9GV5jVu

 

 

 


Mental health care inquiry

Richard Baker and Nick McKenzie

September 6, 2011

From Saturday's front page.

PREMIER Ted Baillieu last night ordered a wide-ranging inquiry into dozens of patient deaths inside Victoria's mental health system.

The inquiry follows a report inThe Saturday Age exposing the high rates of unexpected and unnatural deaths in the state's mental health wards, and raising serious questions about standards of care and allegations of cover-ups.

Today, The Age publishes new revelations about the use of electric shock therapy in Victoria, with documents showing how hundreds of mentally ill people are forced to undergo the procedure without their consent.

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Mr Baillieu's office last night announced that the state's Chief Psychiatrist, Ruth Vine, would investigate the way the state's health services handled all unexpected, unnatural or violent deaths involving mental health inpatients between January 2008 and December 2010.


http://www.theage.com.au/victoria/mental-health-care-inquiry-20110905-1juiy.html

Mentally ill living conditions 'Third World'

Richard Baker and Nick McKenzie

September 7, 2011

SOME of Victoria's most severely mentally ill people are being forced to defecate in cardboard trays and urinate in bottles inside state-run psychiatric wards.

The Age has spoken to several mental health patients who have been placed in seclusion rooms, which are empty except for a mattress on the floor. Many of these rooms have no toilet facilities in order to prevent suicides. Patients and mental health advocates have described the sanitary conditions of the seclusion rooms as ''Third World'' and called on the state government to introduce suicide-proof toilet facilities in Victoria's psychiatric seclusion rooms.

An affidavit filed with the Supreme Court of Victoria in November last year by Bernard Daniels, the father of mental health patient Garth Daniels, referred to his son experiencing ''the most wretched of health disgraces that contravened known sanitary practice'' while placed in seclusion in 2008 under the care of Eastern Health.

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Mr Daniels claimed his son ''was stripped of all dignity and forced by medical and nursing staff to defecate in a tray''.

''Forced to urinate in a bottle. Forced to eat in the same room as having just relieved his bowels into a cardboard tray: a reprehensible and abhorrent throwback to 18th century asylum treatment,'' he stated.

Several other patients have told The Age that they have been forced to wet themselves in seclusion rooms despite banging on the door to ask staff to take them to a toilet.

The concern over toilet facilities comes after Premier Ted Baillieu ordered a wide-ranging inquiry into dozens of patient deaths inside Victoria's mental health system.

The inquiry, to be led by Victoria's chief psychiatrist Ruth Vine, follows a report by The Age that exposed high rates of unexpected or unnatural deaths in mental health wards and raised serious questions about standards of care and allegations of cover-up.

Dr Vine told The Age in an interview in July that patients "had a very valid point" by raising concerns about the standard of toilet facilities in certain mental health wards.

''I agree, using pans, using bottles and paper cups and food on the floor [is unpleasant] … but it is all meant to be about safety,'' Dr Vine said.

She said the Department of Health was improving the standards of seclusion rooms in newer psychiatric facilities as well as reducing the number of people being put into seclusion.

A letter obtained by The Age shows the office of the chief psychiatrist, former Brumby government ministers and the Department of Health were told by the Victorian Mental Illness Awareness Council in 2008 about patient complaints regarding substandard toilet facilities.

''Three patients have made … complaints to me, which included one patient while in seclusion being denied toilet facilities (he was forced to urinate without a toilet) … when he was first placed in seclusion there was a bowl of faecal matter on the floor and a glass of water that had been spat in,'' council director Isabell Collins wrote.



Read more: http://www.theage.com.au/victoria/mentally-ill-living-conditions-third-world-20110906-1jw02.html#ixzz1XDpX0ohL

 

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