Example complaints

Rosa contacted our office with concerns about her daughter Sophia’s recent discharge from an acute inpatient unit. 

Rosa explained that she felt Sophia had been discharged without enough planning or support. Rosa said that she felt the service hadn't adequately communicated with her about Sophia leaving the unit and that even though she spoke with the service about her concerns, Sophia’s discharge had gone ahead.

Not long after being discharged, Sophia was readmitted as an inpatient for further treatment.

At the time Rosa had contacted us, both Rosa and the service manager agreed that Sophia was very unwell and wouldn't be able to provide her consent to the complaint. We determined that there were special circumstances for us to accept the complaint without Sophia’s consent, and that doing so would not be detrimental to her wellbeing.

After speaking with our resolutions officer, the service manager offered to meet with Rosa to discuss her concerns and how to improve communication in future.

Rosa said that while she appreciated the genuine efforts of service staff to resolve her complaint, she was still concerned about the need for improved discharge planning processes at the service.

We assessed the service’s response, identified areas for improvement, and made a formal recommendation that the service review their discharge planning processes.

We asked Rosa if Sophia would now be able to take part in the complaint. Rosa said she was comfortable with us discussing the complaint with Sophia, as she had recently been discharged from hospital.

Sophia agreed to the complaint going ahead, and shared her views on how things could improve.

In response to our recommendation, the service agreed to review their processes, and identified a number of projects that they had initiated to improve discharge planning, including reviewing their clinical practice guidelines with input from carers and consumers and piloting a new discharge procedure with the support of peer workers.

As a result of Rosa’s complaint and other complaints made to our office raising similar concerns, we identified systemic issues in approaches to discharge planning. We discussed these issues and the need for improved guidance for services on discharge planning with the Chief Psychiatrist.  

We have since made a formal recommendation to the Secretary of the Department of Health and Human Services for the issues identified in complaints to be considered in the Chief Psychiatrist’s review of the guidelines for discharge planning for mental health services in Victoria.

Learn more about positive responses to complaints in the Promoting service and system improvement section of our annual report (pp. 41-46).

Please note: We have changed the people's names and omitted some details to protect the identity of all those involved.

Mary made a complaint to our office about her experiences of being placed on a temporary treatment order after being admitted to a hospital general ward. 

Mary described feeling in a state of shock and not understanding why she was being treated as a compulsory patient. She told us that she hadn’t been able to call her lawyer privately, and hadn’t been given any information about her rights. She also spoke about feeling intimidated and threatened by one of the staff members at the service.

Mary explained that she had raised these issues with one of the treating clinicians, as she wanted the service to understand how traumatic her experience had been, and to take action so other people didn’t have similar experiences.

A number of issues were raised under the Mental Health Act 2014 (the Act), including:

• the right to communicate privately
• the provision of a statement of rights
• the principle that people receiving mental health services should have their rights, dignity and autonomy respected and promoted.

We asked the service to provide a formal response, and to outline steps that had been taken to address the specific allegations about the staff member concerned.

At a meeting facilitated by the MHCC, the service acknowledged Mary’s experiences, apologised for what had happened, and said a number of actions had been taken to ensure all staff were aware of their obligations under the Act.

They also advised that the actions of individual staff members had been investigated, and that relevant staff had been counselled. 

Mary said that the experience of being heard and receiving a direct apology by senior management was most important to her, and that she felt the service had taken her concerns seriously.

Mary said she appreciated being asked by the service to share her experiences as part of staff training aimed at preventing other compulsory patients from having similar experiences. 

The issue concerning the alleged conduct of the staff member was investigated by the service, but remained unresolved because of disputed accounts and a lack of witnesses and other evidence.

We identified the need for further review of the adequacy of the investigations and actions taken by the service, and sought confirmation that the Australian Health Practitioner Regulation Agency was considering the notification made about the alleged conduct of the staff member concerned. 

We confirmed the actions taken by the service to ensure compliance with the Act. We also made formal recommendations to the service to address gaps in their local complaints and investigation processes, and to promote improvements in these areas.

Learn more about positive responses to complaints in the Promoting service and system improvement section of our annual report (pp. 41-46).

Please note: We have changed the person's name and omitted some details to protect the identity of all those involved.

Darren, a consumer who had been receiving mental health treatment in hospital for several years, contacted our office about wanting to live in the community. 

We spoke with Darren, together with his case manager, to discuss his concerns about the length of time he had been residing at the service.

In our discussions, the service manager explained that Darren had a cognitive impairment, and that the service had not been able to find accommodation and adequate supports that would meet Darren’s complex behaviour support and daily living needs.

The principles of the Mental Health Act 2014 include the requirement for services to provide treatment in ways that support the consumer’s recovery and full involvement in community life, while responding to their individual needs, including for disability support.

We worked with the service and Darren to explore options for ensuring his treatment was provided in the least restrictive way possible. Our resolutions officer asked the service to further investigate support options through disability services, as well as to create a detailed transition plan that would enable Darren to live in the community.

The service pursued a re-assessment of Darren’s eligibility for disability supports and worked proactively with disability services to identify accommodation and additional supports that would meet his individual needs and complement the clinical support provided by the service.

As a result of making a complaint, Darren and the service now have a clear plan for his move into community supported living, and the service understands the actions they need to take to appropriately assess and respond to people’s disability support needs.

Learn more about positive responses to complaints in the Promoting service and system improvement section of our annual report (pp. 41-46).

Please note: We have changed the person's name and omitted some details to protect the identity of all those involved.

Joshua raised his concerns with us about not being able to access culturally appropriate services as a consumer at his local community mental health service.  

Joshua explained to our resolutions officer that he had asked service staff for a male Aboriginal worker to be involved in his ongoing treatment and care. He told us that he felt his needs were not understood by his treating clinicians, and that he was not comfortable discussing his mental health concerns with a female or non-Aboriginal worker. Joshua had a history of significant trauma and attempts of self-harm. 

In Joshua’s discussions with the service, the service manager explained that they didn’t currently employ a male Aboriginal worker, and that it wasn’t possible to meet his request. 

We identified concerns about the service upholding the principles of the Mental Health Act 2014, including the requirement for services to recognise and respond to the distinct culture and identity of Aboriginal people receiving mental health services. 

We asked the service to consider other ways that they could meet Joshua’s individual needs.

We worked with both the service and Joshua to identify an Aboriginal worker in a neighbouring Aboriginal support service who Joshua felt comfortable with, and who was available to help in developing a recovery and support plan.

We also provided advice to the service on the need for their approaches to be informed by guidelines and resources for providing culturally safe and responsive services.

Learn more about positive responses to complaints in the Promoting service and system improvement section of our annual report (pp. 41-46).

Please note: We have changed the person's name and omitted some details to protect the identity of all those involved.