The Office of the Health Ombudsman (OHO) had received a number of complaints and notifications relating to the Mental Health Service within a Queensland Hospital where nursing and security staff were referred to the Health Ombudsman for consideration of immediate action to address serious risks identified in their conduct and performance of their duties.

In response, a proactive activity was commenced to review all complaints and notifications received by the OHO relating to the Mental Health Service over the previous 12 months, to identify potential systemic issues.

Wider learnings and recommendations for service improvements

The proactive activity highlights the opportunity to improve the quality and safety of inpatient mental health services by:

• Conducting regular audits, reconciling with CCTV recording, to monitor adherence to visual observation requirements.
• Ensuring staff receive appropriate training in violence prevention through conflict resolution and de-escalation techniques.
• Embedding a de-briefing framework for significant incidents that is timely and includes all frontline staff involved, clinical and non-clinical.
• Encouraging the reporting of clinical incidents and occupational violence, ensuring transparent and meaningful feedback to staff regarding quality and safety.
• Reviewing rostering arrangements to optimise teamwork, patient engagement and care planning.
• Implementing processes to ensure clarity in responsibilities for nursing led tasks, including undertaking visual observations.

Read the snapshot report (PDF 140KB)