The Office of the Chief Psychiatrist monitors clinical practice and incidents to promote quality and safety in mental health and wellbeing services.
To enable this oversight role, mental health and wellbeing services must report to the Chief Psychiatrist:
- the use of restrictive interventions
- the use of electroconvulsive treatment (ECT)
- the deaths of people in their care
- sexual safety incidents.
Reporting restrictive interventions
Mental health and wellbeing services are required to submit restrictive intervention data from the previous month via SharePoint on the 10th of each month.
The submitted data must:
- be a scanned copy of the CMI/ODS report
- be signed by the Authorised Psychiatrist or delegate to confirm that they have reviewed and verified the data
- include seclusion registers and all forms of bodily restraint (physical, mechanical) and chemical restraint.
If the use of restrictive practices exceeds a benchmark, services are required to complete an exceeded benchmark report and submit it via the SharePoint portal.
They are also expected to contact the Office of the Chief Psychiatrist contemporaneously to discuss an individual's presentation when a benchmark is exceeded.
Reporting electroconvulsive treatment
Mental health and wellbeing services are required to report the use of electroconvulsive treatment (ECT) and neurosurgery to the Office of the Chief Psychiatrist.
ECT must be reported via CMI/ODS, and include:
- the date, name, UR number, sex and age of each person
- the names of the doctors administering the anaesthetic and ECT
- treatment pulse width, laterality and stimulus intensity
- mental health act status
- the type of consent
- clinical outcome measures.
Services must also notify the Office of the Chief Psychiatrist about adverse events related to ECT that:
- result in a death (or a near miss), serious injury, serious illness and/or
- require transfer to an emergency department or similar setting.
Services must report and review other types of ECT incidents and near misses through their ECT committee and safety-monitoring bodies. Records must be kept of these discussions and corresponding actions.
Services must notify the Office of the Chief Psychiatrist about ECT use that raises highly complex clinical, legal or ethical considerations. This refers to situations that sit outside existing guidelines, standard practices and statuary protections, and may require alternative, individualised models of care.
These complex cases are reviewed by the Chief Psychiatrist ECT Complex Expert Consultation Panel, which advises the Chief Psychiatrist on safeguards in the administration of ECT.
The review process of the Panel does not determine the clinical decisions for the individual’s treatment and care. Rather, it is intended to facilitate learning on future care and treatment with respect to the administration of ECT.
People under 18 years of age
Services are required to notify the Office of the Chief Psychiatrist when ECT is administered to a person under 18 years of age. This notification must take place via email and include:
- information in the application submitted to the Mental Health Tribunal to seek authorisation for ECT
- evidence of a second opinion.
Neurosurgery for mental illness must be reported to the Office of the Chief Psychiatrist.
A written report must be submitted to the Office of the Chief Psychiatrist via email within 3 months of the surgery.
Another written report must be submitted to the Office of the Chief Psychiatrist within 9-12 months of the initial surgery as a follow-up.
Reporting deaths of people in the care of a mental health and wellbeing service
Mental health and wellbeing services must notify the Chief Psychiatrist of all reportable deaths in inpatient, custodial and community settings.
Inpatient deaths at designated mental health services and bed-based mental health units in custodial settings must be reported to the Chief Psychiatrist within 24 hours. This applies to patients who have been discharged or absent from the inpatient until within the previous 24 hours.
Mental health community support services, who have reported under the Mental Health Act 2014, are encouraged to continue to follow this reporting practice under the Mental Health and Wellbeing Act 2022 (the Act).
For all reportable deaths a Notice of Death form (MHWA 125) must be initiated within three working days.
Deaths in community settings that must be reported include:
- patients subject to an order under the Mental Health and Wellbeing Act 2022.
- persons subject to a non-custodial supervision order under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997.
- all unexpected, unnatural or violent deaths in the community of:
- current registered mental health consumers
- people who were seeking or had sought treatment and care from the service in the days prior to their death and did not receive it
- people who had been consumers of a mental health service in the previous 3 months.
The Office of the Chief Psychiatrist must be notified about all inpatient deaths and deaths of persons subject to the Mental Health and Wellbeing Act 2022.
Notifications are not required of deaths due to natural causes of people receiving mental health and wellbeing services on a voluntary basis in the community.
Reporting sexual safety incidents
All sexual safety incidents occurring in bed-based designated mental health services and bed-based mental health wellbeing services in custodial settings must be reported via the . This reporting requirement also applies to specialist mental health services in custodial settings.
The relevant services must send data collated from this reporting process to the Office of the Chief Psychiatrist on a monthly basis.
Sexual safety incidents are alleged, witnessed or suspected occurrences of sexual activity, sexual harassment and sexual assault.
Serious sexual safety incidents that are assigned an Incident Severity Rating (ISR) of 1 or 2 through VHIMS must also be reported directly to the OCP within 24 or 72 hours respectively. The Office of the Chief Psychiatrist reviews all ISR 1 and 2 incidents and works closely with services to ensure that incidents are responded to thoroughly and that risks are addressed.
While the reporting of sexual safety incidents to the Office of the Chief Psychiatrist is an important part of governance, services must also have strong local governance processes to ensure that sexual safety is addressed, prevention strategies are well informed, and risks can be eliminated.
Reviewed 15 September 2023