The report found issues around consent and communication with people with disabilities
It has been recommended that all major SA hospitals implement disability health plans
The report found SA Health breached standards and guidelines of disability care
The Health Complaints Commissioner found South Australian public hospitals failed to deliver appropriate and acceptable care to patients with disabilities in a report that has been hidden from the public for two years.
Health and Community Services Complaints Commissioner Grant Davies investigated seven cases of disability discrimination in public hospitals between 2015 and 2017.
ABC News has now been provided with a summary report of that investigation, which found common issues around consent, attitudes of hospital staff and difficulty communicating with people with disabilities, their guardians and their carers.
The 2018 findings prompted Commissioner Davies to recommend disability health plans be
implemented at all major South Australian hospitals — work that is still in progress two years later.
Mother says her son was 'last on the list'
Dianne Badman's son, Jason Foster, died in the Flinders Medical Centre where he had spent two years. An old photo of Dianne Badman with her son Jason Foster. (ABC News)His case was one of the seven that was investigated by the Commissioner. In 2011, Jason fell and broke his hip and his health began to deteriorate. Four years later, he had a stroke and was taken to the hospital. Dianne Badman says her son was "last on the list" for proper care. (ABC News)Ms Badman said she was often frustrated by the care her son received and said his eventual death from a heart attack could have been prevented.
"He was last on the list, so to speak, and he was denied physio," she told ABC News."For a short, while he received physio, then he was — in our opinion — deemed not worthy." Earlier this month, Ms Badman told ABC News it was, "very, very disappointing" the report had never been made public.
'These were very distressing cases'
Although his predecessor planned to release the full report, Commissioner Davies said he would not — claiming privacy reasons — but he has now released a summary of the report. Associate Professor Grant Davies has released a summary of the report. (Twitter)"I can think of no situation in my career as a complaints-resolution practitioner where the release of expert opinion was appropriate or warranted," Commissioner Davies said.
SA Health was handed the final report in August 2018.
Commissioner Davies found SA Health had breached standards and guidelines and that some aspects of the care provided to these patients had posed an "unacceptable risk" to their health and safety.
"These were very distressing cases and part of the reason my predecessor launched an investigation was that it developed a trend," he said.
"The systemic delivery of acute services by SA Health hospitals at that time posed an unacceptable risk to the health or safety of members of the public with disabilities and their family and carers.
"I find the systemic delivery of acute services by SA Health hospitals to people with disabilities to be in breach of the HCSCC [Health and Community Services Complaints Commissioner] charter's five guiding principles and three of the rights, namely diversity, decision-making capacity and genuine partnership."
Disability health plan for major hospitals
The main recommendation was to establish a disability health plan for major public hospitals.
Commissioner Davies said the Central Adelaide Local Health Network (CALHN), which runs the Royal Adelaide and Queen Elizabeth hospitals, had since developed appropriate disability access and inclusion plan, but he said he was not aware of any of the other local health networks doing the same.
"Clearly systemic improvement takes time and I will be monitoring their progress," he said."Given the seriousness … I'll have a continued interest until those policies and procedures are implemented. Ms Badman's son, Jason, died in the Flinders Medical Centre. (ABC News)"I would expect to see substantial progress by the department by December this year."
In a statement, SA Health said it had accepted the findings from the 2018 report.
"Since the investigation concluded, we have already addressed a number of the issues raised within the report," the statement said.
"This includes establishing a borderline personality disorder clinic, developing the NDIS discharge pilot to streamline the discharge processes for patients receiving NDIS support, and implementing the Centre for Disability Health to support people with intellectual disability.
"Work is also underway on developing disability access and inclusion plans for all our entities, which will be undertaken in consultation with people with disabilities."We are committed to ensuring all people with disability have full and equitable access to health services, resources, decision-making, information and facilities when they are in our care." It said it would report back to the commissioner on its progress in December.