The global spread of the coronavirus, or COVID-19, has changed all our lives in ways we couldn’t have imagined only a few months ago. Here are some updates from the MHCC from pre-COVID-19 times, December 2019 up to March 2020, when we operated as usual.


Staff news

On 26 January 2020, our Commissioner, Dr Lynne Coulson Barr, received a Medal of the Order of Australia (OAM) for services to community mental health and roles in disability, dispute resolution and tribunals. She said: “I am personally honoured and humbled to receive this award, but most importantly it recognises that our work in complaints and dealing with people’s concerns about mental health services is an important service to both individuals and the community’.

In February 2020 we appointed our new Deputy Commissioner, Maggie Toko. Maggie is a lived experience leader who brings a wealth of wisdom and expertise to the MHCC, including extensive experience in senior management and service delivery in community mental health and the welfare sector more broadly. Maggie has taken a year’s leave of absence from her role as CEO of the Victorian Mental Illness Awareness Council (VMIAC) to join the MHCC.

Please note: From 1 July 2020, there will be a change to the role of the Commissioner. The Victorian Government has made a decision that one person will hold the dual roles of Mental Health Complaints Commissioner and Disability Services Commissioner (DSC). Announcements will be made shortly.


Advisory Council

Our Advisory Council website page has recently been updated and information about all members may be found here. We have welcomed two new members: Katrina Clarke and Dean Duncan.

Katrina has worked as a Senior Family/Carer Consultant since 2007 and is currently a Community Member for the Mental Health Tribunal, on the Executive of the National Mental Health Consumer and Carer Forum and on the Board of Tandem. She also supports the Carer Lived Experience Workforce in Victoria.

Dean is the Executive Director of Education for VACCHO and a proud Kamilaroi man who was awarded NAIDOC's National Person of the Year in 2019. He will help the MHCC as we continue to work towards ensuring we are culturally responsive and accessible to Aboriginal Victorians.

During Reconciliation Week 2020, staff were very pleased to participate in a session led by Dean on how to provide meaningful and respectful acknowledgements to Traditional Owners and Custodians, and discuss the wording of the acknowledgement on a special plaque which will be installed in our office upon our return.


Royal Commission into Mental Health

The MHCC has been actively contributing to Victoria’s Royal Commission into the Mental Health System, which will report in October 2020. We provided a detailed submission which was referenced several times in the Royal Commission’s Interim Report. In response to a Notice to Produce, we’ve also provided copies of local complaints reports, a summary of service responses to the recommendations made in our sexual safety report, The right to be safe, and an analysis of sexual safety complaints received in 2017-18 and 2018-19. The Commissioner has also prepared a detailed witness statement that will be published on the Royal Commission’s website. We have also assisted the Royal Commission’s Policy and Research team with a range of resources and contacts for their work.


Complaints made to the MHCC

Complaints during COVID-19

Since the outset of the COVID-19 crisis, the MHCC Resolutions team has been responding to the mental health impacts of the pandemic on mental health consumers and their families. There has been an increase in the level of distress and gravity of concerns expressed by callers seeking assistance from the MHCC, as well as concerns about the impacts on service provision and availability. The MHCC has been meeting weekly with representatives of the Department of Health and Human Services to share these themes from calls and complaints to the MHCC, which have been used to progressively inform the department’s mental health COVID-19 responses.

Complaints to the MHCC have provided a vital window into the emerging experiences of mental health consumers, families and carers during the COVID-19 crisis. The types of issues that have been raised to date include concerns about:

  • consumers being discharged from acute inpatient treatment when they were still too unwell to understand COVID-19 risks and restrictions

  • restrictions on visitors to services

  • risk of infection in acute inpatient units or residential services

  • approaches to infection control, including consumers being expected to stay in their own rooms and not access communal areas

  • availability of community-based treatment and administration of medication

  • suspension of leave from inpatient units, including leave for smoking.

Complaints July to December 2019

Our broader complaints data is now finalised for July to December 2019. In this period:

  • 1,241 matters were raised with the MHCC, including 1,142 complaints and 99 enquiries

  • of the 1,142 complaints, 813 were in-scope, meaning that they were related to an issue about a Victorian public mental health service that occurred since July 2013, a consumer was identified, and they were not about NDIS-funded services

Issues in complaints

The most common issues raised in complaints were:

  • treatment (raised in 59 per cent of complaints). Treatment complaints were most commonly about responsiveness of staff, including inadequate consideration of the views and preferences of consumers, family members or carers. Treatment complaints were also commonly about suboptimal treatment, including disagreement with treatment orders or the least restrictive option not being considered.

  • communication (26 per cent of complaints), most commonly about inadequate or misleading information, including inadequate/incomplete/confusing information.

  • conduct and behaviour of staff and other consumers (23 per cent of complaints) These complaints were most commonly about perceived rudeness or lack of empathy or compassion by staff.

  • medication (22 per cent of complaints) most commonly about side-effects from medication, dissatisfaction with changes to prescribed medication and concerns about unnecessary medication.

  • access (11 per cent of complaints), which is consistent with previous data. Access complaints were most commonly about service availability, including refusal to admit or treat, or lack of or insufficient access to services.

Three-quarters of complaints were raised by consumers, and one-quarter by family members or carers. Consumers were more likely to raise concerns about conduct and behaviour (24 per cent of complaints) and medication (26 per cent of complaints) than family members or carers (17 per cent and 10 per cent of complaints respectively). Family members or carers were more likely to raise concerns about treatment (67 per cent of complaints), communication (32 per cent of complaints), and access (18 per cent of complaints) compared to consumers (57 per cent, 25 per cent and eight per cent of complaints respectively).

Complaints about inpatient settings were more likely to be about treatment (71 per cent) than complaints about community settings (55 per cent). Complaints about community settings were more likely to be about conduct and behaviour, which includes perceived rudeness or lack of empathy from staff (29 per cent) and access (18 per cent) than complaints about inpatient settings (19 per cent and three per cent respectively). Complaints about communication and medication were similar across settings.


Investigations and undertakings

The MHCC has progressed a number of formal investigations in the period 1 July 2019 to the end of March 2020. We finalised investigation reports relating to the use of physical and mechanical restraint, including whether the use of restraint complied with the provisions of the Mental Health Act 2014 and the Charter of Human Rights and Responsibilities Act 2006. In February 2020 we also finalised a report on allegations against staff in an Aged Acute Inpatient Unit (AAIU).

Investigation: Complaint in aged care

This complaint raised significant quality and safety issues including allegations of physical assault, bullying, harassment and intimidation by staff in an Aged Acute Inpatient Unit (AAIU). The MHCC Commissioner found insufficient evidence to make any findings about the specific allegations and no grounds to take any action in respect of individuals.

Many of the allegations were made in the context of the consumer objecting to prescribed medication and reflect the conflicts and potential coercive treatment pursuant to a compulsory treatment order. Concerns were raised about the unit being apparently ill-equipped at the time to provide appropriate care.

Accordingly, the Commissioner made nine recommendations to improve consumers’ experiences, including recommendations to review the model of care and provision of the therapeutic program, improve staff training and development, improve planning for admissions when a person is transitioning between different programs, review age criteria when considering admissions, ensure that debriefing for consumers and staff occurs after incidents, and to review the local complaints process. Individual recommendations were made to develop a re-admission plan for the consumer and to explore resolutions options which acknowledge and address the experience and concerns.

The MHCC is also progressing investigations in relation to:

  • the circumstances in which a person was placed on an Assessment Order and taken to hospital

  • the clinical and legal issues arising from the administration of electroconvulsive treatment to a consumer who also required medical treatment in an intensive care unit

  • the use of physical and mechanical restraint (a separate investigation to the one referred to above).

    The Commissioner has also accepted formal undertakings from services to take specific action in relation to four complaints which raised serious issues of rights and safety. In brief the issues related to: 

  • the removal of a person’s clothing without their consent when the person was in seclusion

  • the use of physical restraint in circumstances that raised serious issues of gender sensitive practice and trauma-informed care

  • compliance with the provisions of the Act requiring information and documents to be provided to a person when an Assessment Order and a Temporary Treatment Order is made

  • breaches of the Act in relation to the use of mechanical restraint.


Education & Engagement


The MHCC is excited to announce that we are now on Instagram! We will be sharing images and stories about mental health, the mental health sector and the activities of the MHCC, among other things.

The MHCC is committed to building our online presence and Instagram provides the opportunity to connect more closely with and further engage young people, for whom Instagram is very popular. We want to help stop the social stigma surrounding mental health challenges, share insights from lived experience and ensure people are aware of their rights and the role of the MHCC while promoting service and system improvement.

Please connect with us on Instagram via @mhcc_vic and to our other social media platforms (Twitter, Facebook and LinkedIn) via the links on We look forward to seeing you there!


In early 2020, MHCC staff particularly enjoyed the opportunity to walk in the MIdsumma Pride March and host a stall at the annual Midsumma Carnival. These were wonderfully diverse, inclusive, safe and joyous celebrations of LGBTIQ culture for a community that faces great mental health challenges because of experiences of stigma and discrimination. We were able to connect with many new people and encourage them to speak up about their experiences in public mental health services in Victoria, with our Commissioner also interviewed with Ro Allen, Victorian Gender and Equality Commissioner, on radio JOY 94.9 FM.

Please see here photos of the Commissioner with Ro, Deputy Commissioner Maggie Toko, Victorian Equal Opportunity and Human Rights Commissioner Kristen Hilton and the  Minister for Mental Health, Martin Foley MP, amongst other attendees. #Midsumma



Our Commissioner, Dr Lynne Coulson Barr, and MHCC staff, continue to engage and educate people in the work of the MHCC through a variety of activities. These include our communications, service meetings, training sessions, information stands, projects, contributions to consultations and various stakeholder activities.

In February 2020 the Commissioner spoke amongst many innovative and dynamic female leaders about ‘the importance of inclusive and collaborative approaches to leadership’ at the 12th Victorian Women’s Public Leadership Summit. She was also pleased to be part of the judging panel for the 7th Premier’s Volunteer Champions Awards and congratulate the 57 deserving recipients, many of whom have supported the mental health and wellbeing of people isolated or at risk.

A further presentation was to educate clinical and operational directors from designated mental health services and Forensicare at the Department of Health and Human Service’s mental health sector forum. Along with Kaaren Dahl, the MHCC’s Manager of Resolutions and Review, the Commissioner also spoke to attendees from various jurisdictions at the Melbourne Mental Health Conference convened by Ausmed.

Emma Bohmer, our Senior Adviser, Lived Experience and Education, has visited two regional mental health services to deliver education and training on responding to complaints, and we are now exploring how best to provide training remotely to interested services. She also presented at St Vincent’s Hospital’s FaCpC and CRC meeting with managers, lived experience staff, consumers and carers as part of the MHCC’s commitment to being driven by lived experience. She also participated in the Mental Health Access and Quality in Emergency Departments conference, which brought together key stakeholders including mental health Clinicians to share new pilot and trial programs, and new models of care to improve outcomes for mental health consumers.

In order to achieve our strategic goals of being accessible and safe for people from diverse communities, all MHCC staff have participated in Aboriginal Cultural Safety Training by VACCHO. We also had training by Transgender Victoria on understanding and responding to the trans and gender diverse community, with some staff also joining a workshop on Trans and Gender Diverse Inclusive Practice run by cohealth. New staff have undertaken orientation visits to St Vincent’s and Thomas Embling hospitals, and some are also completing formal mediation training.


MHCC contributions to consultations, submissions and projects have included:

  • the development of a submission in response to the Productivity Commission into Mental Health’s interim report

  • making a submission on the Disability Worker Regulation Scheme (proposed registration standards and regulations)

  • contribution to the Victorian Nurse Practitioner Prescribing Consultation, to highlight the importance of adequate shared care arrangements being in place to ensure the effective treatment and care of people experiencing mental illness. This input was based on several complaints to our office that have highlighted the serious risks that can arise when shared care arrangements between public mental health services and general practitioners are not effectively implemented

  • contributions to Safer Care Victoria’s Draft clinical guidance on caring for people with acute behavioural disturbance to ensure it is informed by what we have learned from people’s experiences, particularly in Emergency Departments.

  • contributions to departmental advisory and working groups including the Lived Experience Advisory Group, OCP Sexual Safety Committee, Performance Measures Outcome Group, and Safer Care Victoria’s Insight Sub-committee of the Mental Health Clinical Network.