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The consumers who resided at the Oakden Older Persons Mental Health Service (Oakden Facility) were some of the most frail and vulnerable persons in our community. They did not have a voice. They were obliged to live in a facility which could only be described as a disgrace, and in which they received very poor care. The process and procedures were such that they were forgotten and ignored. The State did not provide them with the level of care that they deserved.

Every South Australian should be outraged at the way in which these consumers were treated. It represents a shameful chapter in this State’s history.

It should not have happened. It must never happen again.

I have prepared this report as a consequence of an investigation I carried out into potential serious or systemic maladministration in public administration associated with the Oakden Facility. Later in this report I explain in more detail why I decided to conduct this investigation.

The report is necessarily long and detailed. It highlights systemic failings in processes and oversight that allowed the events at the Oakden Facility to occur for more than a decade largely without intervention.

The evidence I received was astonishing.

It pointed to a regime that existed whereby serious complaints about care were not appropriately addressed.

Mechanisms that were designed to ensure serious matters were escalated either failed or were simply not applied. Those directly responsible for the facility actively sought to manage matters ‘in-house’. A culture of secrecy developed.

Persons in authority outside of the Oakden Facility were unaware of the systemic failings occurring in the facility. They ought to have known of those failings. Opportunities for intervention were missed.

Early in the investigation a number of my staff and I visited the Oakden Facility. My staff and I formed the opinion that it was a disgrace. It should not have been used to house anyone let alone frail and vulnerable consumers.

What occurred at the Oakden Facility is a shocking indictment on its management and oversight.

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