Published on 28 Feb 2018

On 28 February 2018 Commissioner Lander published his report Oakden: A Shameful Chapter in South Australia’s History.
The report makes findings against five individuals and the Northern Adelaide Local Health Network. It also makes 13 recommendations.

A4, 456 pages, PDF 8.92MB

ICAC Report - Oakden: A Shameful Chapter in South Australia's History

In April 2017 the then South Australian Chief Psychiatrist provided a report entitled ‘The Review of the Oakden Older Persons’ Mental Health Service’ to the then Minister for Mental Health and Substance Abuse. The report was released to the public.

On reviewing that report, and in consideration of complaints also made regarding the facility to the Office for Public Integrity, Commissioner Lander formed the view there were potential issues of serious or systemic maladministration in public administration of the facility.

On 25 May 2017, while giving evidence to the Crime and Public Integrity Policy Committee of the Parliament of South Australia, Commissioner Lander announced that he would conduct an investigation into the management and delivery of services at the Oakden facility under (now repealed) provisions of the former Independent Commissioner Against Corruption Act 2012 (SA).

Commissioner Lander was concerned that: “unless it was established how the Oakden Facility and its operations had deteriorated to such a poor state, there was the possibility that such events would be repeated in the future.” (Oakden 2018: 22)

The terms of reference for the investigation focused upon the process and management of complaints, and what action was taken as a result of the complaints made, including whether any attempts were made to disguise or amend information relating to complaints.

The report made findings against five individuals and the Northern Adelaide Local Health Network. It also made 13 recommendations. These addressed:

  • clinical governance and management of the facility;
  • the need for relevant training of all staff, including in relation to reporting obligations;
  • the powers of the Chief Psychiatrist and Principal Community Visitor to conduct inspections, and review of capabilities required for community visitors;
  • review and reporting on the physical condition of mental health service facilities;
  • implementation of the recommendations of the Chief Psychiatrist’s report on the facility;
  • review of the role of the Consumer Advisor; review of the use of restrictive practices in facilities; and
  • review of the level and nature of allied health staff support in facilities.

Following announcement of the investigation, the Minister with responsibility for oversight of the facility resigned. The senior public servants implicated in the report also left the service. The facility itself was closed on July 2017.

The Commissioner’s report was released on 28 February 2018, prior to the March 2018 State election. The State Government at the time responded to the report, accepting all 13 recommendations and indicating how it proposed to implement them.

The Office of the Chief Psychiatrist has published reports outlining the implementation of the recommendations contained in the Commission’s report on Oakden. The final implementation report was published in May 2020.

The exposure of issues at the Oakden facility also had a significant impact at the national level. The Australian Government commissioned a review of the aged care quality regulatory processes on 1st May 2017 in direct response to the failure of the regulatory accreditation process at Oakden.

The Senate Community Affairs References Committee commenced a review into the ‘effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse and poor practices, and ensuring proper clinical and medical care standards are maintained and practised’. The interim report of this review stated that Commissioner Lander’s investigation was a direct response to the apparent lack of action to address the issues raised in the Chief Psychiatrist’s report (The Senate 2018: 36).

The exposure of the operation of the Oakden Facility was cited by the 2021 Royal Commission into Aged Care Quality and Safety as an important catalyst for recognition of the depth of problems in the aged care sector in Australia. In their summary introduction to the Royal Commission report, Commissioners Gatone and Briggs stated:

After years of critical reviews, it took the Oakden catastrophe in South Australia to expose again the cracks in the aged care system.

(Final Report of the Royal Commission into Aged Care Quality and Safety –

‘Care, Dignity and Respect’ Volume 1: 27).