Media release - The Forensic Disability Service report
23 August 2019
Ombudsman presents The Forensic Disability Service report
The Queensland Ombudsman’s report, The Forensic Disability Service report: An investigation into the detention of people at the Forensic Disability Service, was tabled by the Honourable Curtis Pitt MP, Speaker of the Queensland Parliament on Thursday 22 August 2019.
The Queensland Ombudsman, Mr Phil Clarke, said he started the investigation after he received information that raised serious concerns about the treatment of persons detained at the Forensic Disability Service (FDS), a facility for the involuntary detention and care of people found unfit to stand trial as a result of an intellectual or cognitive disability.
The Ombudsman’s report includes opinions about administrative actions by the Department of Communities, Disability Services and Seniors and the Director of Forensic Disability (the department and the director share responsibility for FDS operations) and makes 15 recommendations, under the Ombudsman Act 2001, for improved decision-making and administrative fairness.
“The implementation of these recommendations will support care for the very vulnerable people detained at the FDS, to protect their human rights and to promote their early transition to supported care in the community,” Mr Clarke said.
“This investigation found a wide range of problems in the care of people detained at the FDS including the length of detention, their care during detention, the lack of adequate programs and the use of seclusion and other regulated behaviour controls.”
The investigation found one person detained at the FDS, referred to by the pseudonym ‘Adrian’ in the report, has been subject to back-to-back three-hour seclusion orders for more than six years.
“Upon reviewing the circumstances of Adrian’s case, the investigation found that he had been secluded 99% of the time between admission at the FDS in 2012 and September 2018,” Mr Clarke said.
“Having carefully examined evidence obtained from the FDS, the director and the department, the investigation concluded that the approach to secluding Adrian has been contrary to law, unreasonable, oppressive and improperly discriminatory.
“Overall, the investigation found the FDS was significantly non-compliant with legislation designed to safeguard the care, protection and rehabilitation of the vulnerable persons it accommodated,” he said.
The report
View the full report: The Forensic Disability Service report: An investigation into the detention of people at the Forensic Disability Service
About the Ombudsman
The Queensland Ombudsman is an independent officer of the Parliament.
The Ombudsman ensures public agencies make fair and balanced decisions for Queenslanders by investigating complaints and conducting own-initiative investigations that tackle broader, systemic concerns.
The Ombudsman can investigate complaints about state government departments, local councils and publicly-funded universities.
The Ombudsman can make recommendations to rectify unfair or unjust decisions and improve administrative practice.
Key facts about The Forensic Disability Service report
What is the Forensic Disability Service?
The Forensic Disability Service (FDS) is a medium secure 10-bed facility at Wacol for the involuntary detention and care of people who have been found unfit to stand trial as a result of an intellectual or cognitive disability. The facility is operated by the Department of Communities, Disability Services and Seniors with oversight from the Director of Forensic Disability.
Why did the Ombudsman undertake an investigation into the detention of people at the Forensic Disability Service?
The investigation was initiated as a result of information received by the Office of the Queensland Ombudsman about the quality of care at the FDS.
This information raised serious concerns about the treatment of persons detained at the FDS, particularly: the length of their detention, their care during detention, the lack of adequate programs to support their habilitation and rehabilitation, delays in transitioning them from the FDS to less restrictive environments and the use of seclusion and other regulated behaviour controls.
The investigation covered the period from the opening of the FDS until late 2018.
What were the main objectives of the investigation?
The investigation focused on whether the FDS was providing care, support and protection to people detained in compliance with the Forensic Disability Act 2011 (FD Act).
The Queensland Ombudsman plays an important role investigating the administrative actions and decisions of public sector agencies, particularly when those decisions impact the lives and human rights of vulnerable people living in closed environments.
What investigative powers does the Ombudsman have?
This investigation was conducted under the Ombudsman Act 2001.
When investigating the administrative actions of public sector agencies, the Ombudsman must consider whether their actions are:
- unlawful, unreasonable or unjust
- based on irrelevant considerations
- based on a mistake of law or fact
- wrong.
The Ombudsman is empowered to make recommendations to the principal officer of an agency that action be taken to rectify maladministration to improve the agency’s policies, practices or procedures to minimise the prospect of similar problems reoccurring.
What are the key issues in the report?
- Building blocks of good administrative practices not met
(policies and procedures – see p. 36-38) - Concerns with the care and support of people detained
(plans and programs – see p. 39-56) - Detention periods and delays in transition
(transition – see p. 107-114) - Regulated behaviour controls
(regulated behaviour controls p. 62-64, behaviour control medication p. 65-77, seclusion, including ‘Adrian’ case study – p. 78-92) - Police attendance and criminal charges
(including ‘Adrian’ case study – p. 93-107)
What did the Ombudsman do in the investigation?
The Ombudsman’s investigation involved interviews with key stakeholders including: the Director, officers of the Department, the FDS, the Office of the Public Guardian, the Office of the Public Advocate, the Queensland Mental Health Commission, NGOs and experts identified as relevant to the scope of the investigation.
The investigative team also conducted a site visit, which included inspection of the physical facility and inspection of a large volume of files.
The report also includes an overview of forensic disability orders and background to the FDS, including information about previous investigations and inquiries (Part A of the report – from page 6).
What were the key findings?
Overall, the FDS was found to be significantly non-compliant with legislation designed to safeguard the care, protection and rehabilitation of the vulnerable persons it accommodated.
The investigation also found that there was no clear understanding between the Department and the Director about who was responsible for compliance at the FDS. Weaknesses were routinely identified over many years but little action was taken.
The report makes recommendations to both the Department and the Director because of their shared responsibility for ensuring the FDS meets its statutory obligations to care for the very vulnerable people detained there, to protect their human rights and to promote their early transition to supported care in the community.
Where are the recommendations?
The Ombudsman formed 15 opinions based on the investigation and made 15 recommendations for change at the FDS. The opinions and recommendations are throughout the report with supporting information.
A consolidated listing of opinions is available from page ix – xiv and recommendations from page xv-xix of the report (following the executive summary).
What happens next with the recommendations?
The Ombudsman does not have the power to enforce recommendations.
The Ombudsman will monitor implementation of the recommendations over the next 12 months.
What response was there from the agencies concerned?
As required under the Ombudsman Act, relevant sections of a proposed report were provided to the Department, the Director and the Administrator of the FDS for their individual responses. The final report contains a fair representation of their responses, where applicable.
[ends]
Media contact:
Leanne 07 3005 7007
or media@ombudsman.qld.gov.au