Department of Health and Human Services
CHIEF HEALTH OFFICER
File No.: WITS 58608
Clinical Assessment of Ashley Youth
Detention Centre's current Policy and
Protocols for Health Issues
30 November 2010
Contents
Appreciation
Special Note Regarding the Nature of this Clinical Assessment
1
1
Executive Summary
2
Background
3
Methodology of the Clinical Assessment
4
Findings
5
Health and Wellbeing Unit
5
Data about Ashley from the 2009-2010 Financial Year
5
Clinical Staffing
8
Standard Operating Procedures Relevant to Clinical Matters, Medication Guidelines,
Assessment Forms and Other Documentation
8
Staff Induction and Training
8
Facilities of the Health and Wellbeing Unit
9
Clinical Staff Professional Support and Development
Recommendations
10
11
Acknowledgement
12
Policy Confirmation
12
Accreditation and Ongoing Advice
12
Health and Clinical Arrangements and Standard Operating Procedures
13
Facilities of the Health and Wellbeing Unit
14
Equipment
15
Clinical Governance
15
Clinical Staffing
16
Staff Development and Training
17
Implementation
17
Glossary
18
Appendix
19
Attachments
23
References
24
Appreciation
Appreciation
The members of the Clinical Assessment Team (the CAT) express their appreciation to the Minister for
Children for providing the opportunity to contribute to the improvement of clinical arrangements in place
at Ashley Youth Detention Centre (AYDC) through undertaking this clinical assessment and providing
recommendations for the Minister’s consideration.
We also express our appreciation to the Ashley clinical and management staff for their open and responsive
handling of our questions and during our visits to AYDC and, more importantly, for their visible
commitment to the wellbeing and welfare of Tasmanian youth in detention.
Special Note Regarding the Nature of this Clinical Assessment
There was a death in custody of a detainee on 25 October 2010, for which our condolences are extended
to the family and friends of the deceased. Whilst this tragic event was the trigger for the commissioning of
this clinical assessment by the Minister, this event and the circumstances leading to it are not themselves
the subject of this clinical assessment. The terms of reference of this clinical assessment are provided at
Attachment A.
The intent of the recommendations arising from this clinical assessment is to make improvements in the
clinical arrangements in place at Ashley. They make no representation made regarding whether they would
have altered the course of events leading to the recent death and they should not be read in this way.
There are separate investigations being undertaken by the Coroner and also in accord with Department of
Health and Human Services (DHHS) policy in relation to serious events. These will both look closely at
the facts of the death in custody and make their own recommendations, in light of which these clinical
assessment report recommendations should be revisited to confirm that the most appropriate arrangement
are in place for the future clinical care of Tasmanian youth in detention.
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Executive Summary
This report is prepared for the Minister for Children, the Hon Lin Thorp, (the Minister) in response to her
request to the Chief Health Officer (CHO) of 27 October 2010.
This report is the response to the Terms of Reference for the Clinical Assessment (CA) as provided at
Attachment A.
The CHO assembled a suitably senior and experienced Clinical Assessment Team (CAT) with a clinical
background, including relevant experience of caring for youth in a custodial setting, to assist with the CA.
The CAT visited Ashley to view the clinical facilities and equipment, talk with clinical and management staff
and reviewed data and documents provided which describe the nature of the health needs of detainees and
the clinical arrangements to meet them.
As a result of the helpfulness and commitment of the Ashley staff it was possible for the CAT to assess the
current clinical arrangements and form recommendations for how they might be improved.
Recommendations are provided for shorter-term and longer-term action. They have been organised under
the following headings:
•
Acknowledgement
•
Policy Confirmation
•
Accreditation and Ongoing Advice
•
Health and Clinical Arrangements and Standard Operating Procedures
•
Facilities of the Health and Wellbeing Unit
•
Equipment
•
Clinical Governance
•
Clinical Staffing
•
Staff Development and Training and
•
Implementation.
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Background A
Background
For the purpose of this report, young people in detention are referred to as ‘detainees’.
The Tasmanian legislation relevant to the Ashley Youth Detention Centre is the Youth Justice Act 1997 (the
Act). It is:
‘An Act to provide for the treatment and punishment of young persons who have committed
offences and for related purposes’
The Ashley Youth Detention Centre is a premises declared by the Minister under the provision of Part 6
Division 1 of the Act and published by notice in the Gazette to be a centre:
‘for the detention of –
(a)
youths sentenced to a period of detention and
(b)
youths remanded in custody while awaiting the determination of proceedings for an offence
and
(c)
persons in the process of being transferred to another State under this Act.’i
The Act also states in ‘Division 3 - Treatment of detainees, &c.’, Section 129 in relation to the ‘rights of
detainee’ that:
(1)
A detainee is entitled –
(c)
to have reasonable efforts made to meet his or her medical, religious and cultural needs
including, in the case of a detainee who is an Aboriginal person, his or her needs as a
member of the Aboriginal community’.
The DHHS website explains the role of Ashley within the wider system of Youth Justice Services, in that:
‘Youth Justice Services is responsible for the delivery of restorative justice services to the victims and
perpetrators of youth crime aged 10 to 17 years. These principles and objectives are contained in the
Youth Justice Act 1997. Community based services are provided in the North West, North and the
South and Custodial Services are provided at Ashley Youth Detention Centre, (AYDC), in the North
near Deloraine.
Youth Justice Services provides assistance for young people in conflict with the law through the
provision of different orders by the police and magistrates. These are community conferencing,
community service orders, supervision support and custodial services.
The focus is on working together with the community and the young people, with the emphasis
placed on encouraging young offenders to take responsibility for their offences.’ii
The (national) ‘Standards for Juvenile Custodial Facilities, Revised Edition March 1999’iii, developed by the
Australasian Juvenile Justice Administrators state in Standard 6.1, regarding health care, that:
‘Young people have access to a comprehensive range of health care and health promotion services
and programs that improve and maintain their health and well-being.’
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Methodology of the Clinical Assessment A
Methodology of the Clinical Assessment
This Clinical Assessment was commissioned via a letter of request, dated 27 October 2010, from the
Minister for Children to the Chief Health Officer, Dr Craig White and which also provided Terms of
Reference to be met.
In consideration of the range of skills which would support a comprehensive and informed clinical
assessment, the Chief Health Officer established a Clinical Assessment Team (CAT) comprising:
•
Dr Craig White, Chief Health Officer (CHO)
•
Dr George Cerchez, Director Medical Integration and Workforce
•
Ms Gina Butler, Director of Nursing Primary Health and Manager DHHS Safety and Quality Unit and
•
Dr Chris Wake, Clinical Director, Correctional Primary Health Service, Risdon Prison.
The clinical assessment process itself involved:
•
obtaining and reviewing initial briefing information from Ashley about clinical arrangements in place
there
•
a meeting on-site at Ashley between the CAT and the Manager Custodial Youth Justice
•
a meeting on-site at Ashley between the CAT and the Clinical Nurse Consultant, Ashley Health and
Wellbeing Unit
•
a meeting off-site between the CHO and the General Practitioner (GP), Ashley Health and Wellbeing
Unit
•
the CHO visited the Prison Primary Health Service at Risdon Prison to view demonstrations and
assess the suitability of the Prison Health Pro clinical information system and clinical
videoconferencing equipment for Ashley
•
obtaining and reviewing further information from Ashley about clinical arrangements in place there
•
various additional email and telephone communications between CAT members and with those from
whom information was sought to inform the clinical assessment and develop appropriate
recommendations
•
a follow up meeting with the Manager Custodial Youth Justice, GP and Clinical Nurse Consultant
(CNC) to clarify facts and obtain feedback about the direction of the draft recommendations and
•
requests to the Ashley Manager, GP and CNC to provide any further information at any time that
they believed needed to be taken into account for the purpose of undertaking the clinical assessment
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Findings A
Findings
Health and Wellbeing Unit
Wellness and primary health care services for detainees at Ashley are provided on site by the clinical staff
of the Health and Wellbeing Unit. These are supplemented by referral to external service providers for
more complex or other services not locally available. Where emergency department or admission is
required the detainees are referred to the Mersey Community Hospital or Launceston General Hospital.
The Health and Wellbeing Unit reports operationally to the full-time Manager of Professional Services and
Policy, who in turn reports to the overall Ashley Manager - the Manager Custodial Youth Justice. There is
a rotating roster for the After Hours On-call Manager.
The Ashley Nurse and the GP provide a range of clinical services, which include health risk assessment as
well as assessing and treating health issues as they arise. The Clinical Nurse Consultant also provides
educational sessions tailored to the detainee’s needs as well as working with custodial and other staff to
guide decision making regarding a health issue for a detainee. This holistic view of primary care was seen as
very important and that it should be maintained as a strong foundation on which to build.
Data about Ashley from the 2009-2010 Financial Year
Detainees
The average daily number of detainees at Ashley in 2009-2010 was 28. In 2010-2011, as at
31 October 2010, the number of detainees in Ashley was 26.
The number of admission events in 2009-2010 was 246. In 2010-2011, as at 31 October 2010, the number
of admission events was 59.
Of the detainee admissions in 2009-2010, 85 per cent were male and 15 per cent were female.
Age cohort (years, inclusive)
Percentage of 2009-2010 admissions
10 to 12
2%
13 to 14
20%
15 to 16
46%
17 and above
32%
Total
100%
New arrivals are either remanded or sentenced to custody by the Court and present at any time of the day
or night, seven days per week, three-hundred and sixty-five days per year.
The average duration of detention is five weeks.
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Findings A
This data demonstrates a high rate of detainee turnover with a relatively brief duration of stay during which
health risks can be addressed, compared with the Risdon Prison population. Both the high turnover rate
and the intensity of intervention demanded by the short duration of detention require well-organised,
appropriately resourced and carefully planned clinical service arrangements which can be provided on a
24 hours per day, 7 days per week, 365 days per year basis to support safe admission and release as well as
respond to health events arising during detention.
This finding is reinforced by any additional challenges arising from detainees’ health status, the presence of
health risks and the likely lack of previous access to health-promoting education and intervention.
Financial
The total Ashley budget was $8 841 900.
The budget for direct provision of health services was $168 800, of which $138 000 was for salaries and
$30 800 for medical and pharmacy supplies and other items.
In simple terms, this current spend of 1.9 per cent of budget on the provision of direct health services including education and prevention activities by clinical staff, represents an opportunity the
recommendations of this clinical assessment to provide significant health and wellbeing gains through a
relatively modest increase in funding against the overall cost of running Ashley.
Clinical Activity and Needs
The detainees were described as having complex health needs and higher levels of health risks than an
age-matched population in the wider community.
There were 1 131 occasions of clinical service provided by the Ashley Nurse and an additional
503 provided by the GP.
Data is not available on the actual number of health issues arising out of the hours that there is no on site
clinical staffing. An estimate was provided that 65 per cent of the 1 131 appointments are referred during
normal business hours and 35 per cent outside normal business hours. Taken as a guide to plan service
arrangements, this pattern would suggest that the current daytime bias of on-site work should be
maintained and extended to seven days. It also suggests that there should be improved access to after
hours clinical support via on-call and telehealth links to maintain a more consistent level of clinical cover.
There were 23 occasions on which detainees were taken off site for medical assessment/treatment. Of
these, 17 were for specialist medical referral and six were for Emergency Department attendance. There
were another seven occasions on which detainees were taken off site for dental services.
In 2010-2011, as at 31 October 2010, there were six occasions on which detainees were taken off site for
medical assessment/treatment. Of these, four can be categorised as specialist medical referral and two as
Emergency Department attendances. There were another 18 occasions on which detainees were taken off
site for dental services.
Clinical care was described as being sometimes ‘frustrating’ as even ‘easy things are difficult’ due to the
limited range and scope of on site clinical services and the complexity and security risk of taking a detainee
off site to attend for a clinical investigation or treatment service. The CAT saw this as having the potential
to be a barrier to providing a standard of care that would be provided in a more conventional clinical
setting. The finding was that efforts should be made to increase local diagnostic capability with the
acquisition of some additional equipment and to make arrangements for access to suitably skilled clinical
assessment and advice on a 24 hours per day, 7 days per week, 365 days per year basis.
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Findings A
This situation is at times exacerbated by the challenge of a unique patient population in which it can be
difficult even for experienced clinical staff to assess and reach clinical decisions. Clinical staff have to be
mindful that in this setting, any clinical decisions can have an impact on behaviour and some risk of fostering
attention-seeking behaviour. It was acknowledged as this abnormal illness behaviour can co-exist with a
genuine clinical need and so it was reassuring to the CAT that the decision making was reported as placing
greatest emphasis on the assessed clinical need.
The GP reported that the most likely acute clinical conditions which detainees experience are asthma and
suicide attempts. These risks suggest that physiological monitoring should be available 24 hours per day,
7 days per week, 365 days per year to help with clinical assessment and decision making and that oxygen
can be administered whilst clinical assessment and possibly transfer to an acute setting is being organised.
Existing processes carefully assess and manage the risk of suicide and have not been considered further
here.
The GP also described that the detainee patient population has at times very complex care needs, noting
that general practice issues seen at Ashley have ‘not just adolescent health needs, they are special’. Clinical
issues of particular note in this patient population were noted as being:
•
mental health
•
physical trauma
•
skin
•
genitourinary
•
orthopaedic
•
sexual health
•
drug and alcohol use and
•
dental.
There are two mental health practitioners, a psychiatrist and a psychologist, who visit Ashley regularly to
provide services and undertake clinical and forensic assessments. These arrangements were not reviewed
as part of this clinical assessment.
Dental care is currently provided at a Kings Meadows public clinic of the DHHS Oral Health Service.
Whist the GP was concerned that ’50 per cent (of detainees) have terrible teeth’ the relatively low rate of
transfer for off-site dental care indicates that there is significant improvement possible in access to dental
care. This would ideally be done on an in-reach basis as much as possible to minimise the security
implications of off site transfer for dental care. This arrangement is something to be explored with the
DHHS Oral Health Services and would need some provision within the proposed upgraded facilities for a
dental chair and related equipment within the proposed treatment area. The chair and sterilising
equipment would be able to be shared with the medical practice to improve the local ability to treat minor
injuries. Another option to be explored is the use of the mobile van-based dental service.
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Findings A
Clinical Staffing
The Health and Wellbeing Unit is staffed by a highly qualified and appropriately experienced full-time nurse
who has been working in the role, the responsibilities of which can be defined into the higher level
assessment, education and oversight functions of CNC and the direct care functions of the Ashley Nurse
(AN). This was understood to have been a difficult role to fill. The current staff member has been in this
role since 2003 and in this time undertaken many initiatives to develop the Health and Wellbeing Unit, the
professional role and services provided to detainees but there is a need to extend the AN direct nursing
care hours to provide wider coverage of the week to a seven day nursing service, support the operations
of the clinic and also free up time for the CNC role to be more active in supporting health risk reduction
activities.
There is also an experienced visiting General Practitioner (GP) for four hours each week on a Friday
morning. The GP works the rest of the week in private general practice in a North West town. This was
understood also to have been a difficult role to fill.
That these roles were hard to fill was not surprising to the CAT. The commitment of the incumbent staff
and the efforts that they have made to have a positive impact on detainee health were seen as
commendable and worthy of acknowledgement.
There are no formal after hours on-call arrangements for access to the clinical staff. There should be a
properly organised on-call roster for the Ashley Nurse.
Standard Operating Procedures Relevant to Clinical Matters,
Medication Guidelines, Assessment Forms and Other
Documentation
Staff provided copies of extensive documentation in the form of Standard Operating Procedures relevant to
clinical matters, medication guidelines, assessment forms and other documentation as listed in Appendix 1.
The governance process for sign-off for a policy or procedure at Ashley is the Executive Management Team
(EMT). This process was regarded by the CAT as being appropriate though noted, without providing a
specific recommendation on this point, that if there is a matter of clinical policy recommended by the
Health and Wellbeing Unit which the does not support that it seeks the assistance of some additional
clinical perspective to resolve the issue.
Staff Induction and Training
The provision of secure care to youth in a custodial setting is a highly specialised work setting which
requires a significant investment in helping new staff to develop and maintain competence in the skills
required. Ashley appears to handle this well, overall.
Since approximately 2002, Ashley has had a comprehensive staff training regime which includes ongoing
training in a number of important areas such as suicide prevention, Non-Violent Crisis Intervention and
First Aid, including cardiopulmonary resuscitation (CPR).
Ashley employees its own Training Coordinator dedicated to the coordination and management of this
training regime. Since 2002, the proportion of Ashley Operational Staff trained in these areas has been
increased dramatically from below 5 per cent in 2002 to in excess of 90 per cent now. All Operational
Staff must attend four paid and rostered training days each calendar year.
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Findings A
In 2004, Ashley introduced a comprehensive induction program for all commencing Operational Staff. This
induction program features 13 days of learning, comprising both classroom based training and on the job
learning. The induction provides participants with an introduction to the issues, concepts, practices and
procedures that confront Operational Staff in a custodial environment. The successful completion of First
Aid training is an essential criterion for the satisfactory completion of this comprehensive induction
program.
Ashley also has as the minimum requirement for its Operational Staff Certificate IV in Youth Work
(Juvenile Justice). This is the qualification adopted throughout Australia and New Zealand by the
Australasian Juvenile Justice Administrators (AJJA). Amongst the fifteen units that comprise this
qualification is one relating to the application of First Aid (Unit Number HLTFA301B). The Tasmanian
Skills Institute is engaged to deliver this qualification at the facility.
Appropriate additional orientation and education should be made available for any new clinical staff. Senior
clinical staff should assess the specific needs of the new clinical staff member and tailor a program on a
case-by-case basis in order to best introduce them to this practice setting.
Facilities of the Health and Wellbeing Unit
The facilities comprise:
•
two small clinical rooms located on the corner of a building, one used as the doctors office and the
other as the CNC and Ashley Nurse office in which hard copy files are also held and
•
a wall-mounted seat in an open corridor which is being used as the waiting area.
The rooms were clean and well maintained but were more cluttered with furniture and equipment than is
desirable. Some equipment was unsecured and therefore potentially usable as a weapon or to block the
door from being opened. In addition, each room had only one access door.
The room doors and walls seemed to allow more ready sound transmission than desirable in a clinical
setting.
The above features of the facilities suggested that they would not likely meet contemporary standards for
general practice consulting rooms and may present a security risk. For these reasons there are
shorter-term and longer-term recommendations in relation to improvement of these facilities.
Clinical equipment was limited and there is a recommendation about purchasing additional equipment to
enhance on-site diagnostic capability to a level seen as appropriate in this setting.
The low reported frequency of out of hours clinical events reported might be an undercount of the actual.
The view of the CAT was that there are likely more times when there would be benefit from earlier clinical
assessment or review. The absence of formal arrangements, the difficulties in accessing clinical assessment
or advice outside the work hours of the Ashley clinical staff and the security-related difficulties associated
with getting external assessment by transferring the detainee to a community service are all likely to inhibit
early assessment or review.
The current on-site clinical service arrangements in place at Ashley are regarded as suitable whilst there is a
nurse on site though noting that this needs to be better supported by reliable arrangements to provide
advice and assessment when it is required.
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Findings A
Outside the hours that there is a nurse on site at Ashley, there is currently no formal roster to reliably
obtain clinical assessment and advice. It should be noted that the CNC is available informally and has had
to attend Ashley to provide on-site services from time to time including during a period of recent sick
leave. To replace this approach, reliable arrangements need to be in place outside the full-time
employment hours of the CNC so that entry and exit assessments can be done when they are needed and
there is access to a timely response for any new clinical events at any time.
The Correctional Primary Health Service (CPHS) at Risdon Prison is believed to represent the most
suitable clinical service provider in Tasmania with which the clinical staff from Ashley can partner to
develop a collaborative and supportive working model tailored to the requirements of Ashley detainees and
the clinical setting there.
The CPHS is staffed by suitably qualified and experienced nurses on a 24 hours per day, 7 days per week,
365 days per year basis and also medical cover on site or on call. This level of cover is sustainable with
Risdon’s larger patient population of 500 and 1 200 admissions and a similar number of discharges. At
Ashley there is a much smaller average population in the region of 26-28 detainees but a higher rate of 220
turnover events and their related demands on clinical time. As turnover events happen at any time of the
day or night it is important that there are arrangements reliably in place for an adequate level of timely
initial assessment and follow up. Admissions are a significantly larger driver of clinical activity than the
clinical demands associated with the typical number of detainees.
It can provide 24 hours per day, 7 days per year, 365 days per year clinical support via telehealth
videoconferencing facilities. It already does this for the Launceston Remand Centre, where it has proven to
be extremely successful in providing timely access to expert clinical assessment and care.
This telehealth support means that expert medical assessment and advice can be accessed at any time as
the on-call doctors have the equipment installed in their homes as well as at work. The Ashley GP would
be able also to have this installed at their home and practice address. This would allow them to more
easily participate in clinical meetings as well as be part of an on-call arrangement if they wished to take this
on.
Initial assessments of new detainees, exit assessments or responses to new clinical events can all be done
by this means.
The current clinical governance arrangements are fairly extensive for the CNC but are otherwise limited
and these would benefit from enhancement including a multidisciplinary approach with regular and routine
involvement of the GP in the weekly in clinical review meetings.
Clinical Staff Professional Support and Development
CAT members were impressed by the professional resourcefulness of the clinical staff. The CNC obtains
appropriate professional supervision for her nursing practice and the GP uses existing networks for backup
and support.
CAT members were concerned by the lack of arrangements for professional development and support of a
nature justified by working in a difficult clinical setting. There are recommendations in relation to
professional development planning and funding to support this and prevent the risk of professional isolation.
Improvements such as this will reduce some of the difficulties experienced in the past with recruitment,
retention and succession planning.
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Recommendations A
Recommendations
The Clinical Assessment Team makes the recommendations set out below for consideration by the
Minister for Children. These are to be read in consideration of the following:
•
In proposing these recommendations, careful consideration was given to the special clinical and
security circumstances at Ashley to offer recommendations for improvements which are believed to
offer Ashley detainees an appropriate level of health education, prevention, health risk management
and clinical care as well as provide the Ashley staff a more sustainable and supported working
environment.
•
Recommendations are grouped under headings which refer to the ‘action area’ of the which follow
•
Recommendations are classified into SHORTER-TERM (ST) and LONGER-TERM (LT) to
differentiate between those recommendations for which early action is justified and feasible from
those which will likely require a longer lead time or more detailed project planning, whilst still being
of value to improvement of the clinical arrangements at Ashley. Shorter-term recommendations are
those which the CAT would wish be seeing achieved within six months. Longer-term
recommendations are those which cannot likely be achieved within the shorter-term but which
should still be addressed as soon as realistically possible and preferably take no longer than two
years. The longest-term recommendation will likely be that that in relation to upgraded clinical
facilities, able to meet RACGP accreditation standards, as the planning and construction of these will
have a longer lead time.
•
These recommendations propose clinical support and governance arrangements be established with
the DHHS Correctional Primary Health Service (CPHS). CPHS is a clinical unit within DHHS
Statewide and Mental Health Services. It is the clinical team of the DHHS which currently provides
primary health clinical services in and to a range of justice settings; including Risdon Prison, the
Launceston Remand Centre and Hayes Prison Farm. CPHS clinical staff have extensive experience of
providing clinical services in a secure environment. We also recognise that there are differences to
be taken into account when developing arrangements between the Ashley Health and Wellbeing Unit
and the CPHS. These differences include the younger age of detainees at Ashley, which means that
there are youth and young adult health issues there. Also, that Ashley is a detention centre and not
a prison. These differences are regarded as manageable within the collaborative and supportive
working relationship proposed here. There is value and strength of this clinical alignment arising
from the fact that both parties will likely derive benefit though using their shared experience to
inform health risk reduction and health service improvements in both settings.
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Recommendations A
Acknowledgement
We recommend that:
1
The Minister acknowledges the positive efforts and genuine commitment of the Ashley clinical and
other staff to the wellbeing of detainees with complex health needs in a secure setting (ST).
Policy Confirmation
We recommend that:
2
The policy position be confirmed that Ashley detainees have arrangements for the provision of
primary health care to a standard broadly comparable to that which should be available to them if
they were living in the wider community.
The arrangements should:
•
take account of the custodial setting within which they must be provided
•
meet contemporary primary care standards
•
be age-appropriate for Ashley’s detainees
•
take a holistic primary care approach which encompasses clinical care, prevention and risk
reduction and
•
be justified by the number of detainees at Ashley and their clinical needs.
Accreditation and Ongoing Advice
We recommend that:
3
The primary care facilities at Ashley:
3.1
Consider and make improvements to respond to those contemporary practice standards
http://www.racgp.org.au/standards of the Royal Australasian College of General Practitioners
(RACGP) accreditation program which are relevant to the clinical practice setting at Ashley.
This program is administered by the Australian General Practice Accreditation Limited
(AGPAL). It is important to note that it is not likely that the nature of the practice at Ashley
would render it suitable to undergo accreditation by this process, designed for
community-based practice although this possibility should be explored (ST).
3.2
Consider seeking Australian Council of Healthcare Standards (ACHS) accreditation of the
Ashley health and wellness facility (LT).
3.3
Seek advice every three years from the Division of General Practice Northern Tasmania in
relation to ongoing improvements in clinical and practice management (LT).
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Recommendations A
Health and Clinical Arrangements and Standard Operating
Procedures
We recommend that:
4
Clinical advice and assessment is made available 24 hours per day, 7 days per week,
365 days per year, including for timely assessment of new admissions as well as for new issues
arising at any time requiring clinical oversight, through collaborative and supportive clinical, video-link
and administrative arrangements with the CPHS at Risdon Prison. These will be similar to the
arrangements which successfully support the Remand Centre in Launceston and will be developed in
close consultation with the Ashley clinical staff to take account of the clinical and security
circumstances at Ashley, including clinical staffing levels. Sustainable achievement of this arrangement
will require an additional investment in nursing time to offset the additional workload at the CPHS
(ST and LT).
5
Health risk assessments are:
5.1
Undertaken according to a health risk assessment protocol and assessment format tailored to
the specific needs of the youth population at Ashley, to be developed by the Ashley clinical
staff through working with the CPHS at Risdon Prison (ST).
5.2
Implemented routinely:
○
At reception (ST):
○
5.3
6
by intake staff at entry to Ashley.
Then followed up by an appropriately skilled clinical professional after arrival at Ashley
and which can be performed remotely via video link as clinically appropriate (ST):
by a nurse within 24 hours and
by a medical practitioner within 72 hours.
○
Then reviewed as needed at the next Friday morning general practitioner clinic on site
at Ashley.
○
At exit, noting that all detainees should have a discharge/exit plan and receive a
discharge/exit review at which the health risk assessment can be reassessed and any
changes recorded - which could be performed remotely via video link. The ‘before’ and
‘after’ health risk assessment scores should be recorded and be part of the data
reviewed for clinical governance to demonstrate the health-risk impact of education and
services during detention and support future service improvement efforts (ST).
With referrals being made with appropriate urgency following the risk assessment, including
any need for immediate clinical intervention or prescribing (ST).
Clinical record keeping by all clinical practitioners which:
6.1
Contributes to a single integrated clinical record for each detainee.
6.2
Uses a single web-based information system platform which is based on the Prison Health Pro
(PHP) information system already in use by the Correctional Primary Health Service at Risdon
Prison to facilitate remote clinical support through access to local clinical records and which
should include any essential adaptations to take account of Ashley particular clinical needs of a
youth population in consultation with local clinicians (ST).
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Recommendations A
7
6.3
Has the health risk assessment being embedded within the PHP information system (ST).
6.4
Includes results from pathology, imaging and correspondence or reports from any care
provided outside Ashley (ST).
6.5
Provides security and confidentiality arrangements to appropriately control access to
justice-related and forensic records separately from clinical records (ST).
6.6
Is viewable by all clinical practitioners including those involved with providing remote clinical
support or consultation (ST).
6.7
Supports continuity of clinical care in settings beyond Ashley and referral information (ST).
Medication arrangements are reliably in place and documented which enable:
7.1
Prescribing to be done 24 hours per day, 7 days per week, 365 days per year as clinically
required, preferably using a prescribing module of the PHP provided that this can be
implemented at modest cost (ST).
7.2
Timely dispensing of medication prescribed out-of-hours - either at the point of intake health
risk assessment or prescribed following clinical assessment of a new health issue (ST).
8
Standard operating procedures relevant to clinical matters, medication guidelines,
assessment forms and other documentation are to be updated to reflect these
recommendations (ST).
9
Dental care arrangements are explored with DHHS Oral Health Services to consider bringing into
Ashley some primary dental care services on an in-reach basis with consideration of providing:
9.1
The possibility of mobile equipment being provided to initiate a service in the shorter-term to
provide lower acuity care ahead of the clinical facility becoming available (ST).
9.2
A suitable facility within the clinical precinct with the ability to share space and equipment with
the primary care medical service (LT).
Facilities of the Health and Wellbeing Unit
We recommend that:
10
The Health and Wellbeing Unit Facilities are upgraded to meet the relevant general practice
accreditation standardsiv of the Royal Australasian College of General Practitioners (RACGP)
accreditation program administered by the Australian General Practice Accreditation Limited
(AGPAL). These contemporary standards include enhanced safety-related design requirements
which will also improve the working environment for Ashley clinical staff. (LT)
This recommendation includes, but is not to be limited to:
10.1 Providing a treatment and procedural room separate from the consulting rooms and within
which minor procedures, clinical assessments and in-reach dental services can be undertaken
(LT).
10.2 Providing improved privacy and confidentiality for those waiting to be seen and treated by
better separation and acoustic containment (LT).
10.3 Providing the CNC with an office for their non-clinical work which is separate from the room
in which the Ashley nurse clinical function is practiced (ST).
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Recommendations A
10.4 Addressing security risks by minimising unsecured items and furnishings in clinical rooms or
replacing them with fixed items or removing them altogether (ST).
10.5 Addressing security risks by providing an alternate exit (ASAP but may be LT).
10.6 Undertaking a security risk review of the current areas and taking other early measures based
on that review (ST).
Equipment
We recommend that:
11
12
Clinical equipment is purchased for the Ashley clinical suite, selected and installed in a manner
appropriate to the secure setting, to allow improved diagnostic and treatment capability for common
conditions (ST):
•
Spirometry.
•
ECG.
•
Fixed-mount Auroscope and Ophthalmoscope.
•
Simple-to-use physiological monitoring equipment including for pulse oximetry and blood
pressure measurement and portable oxygen equipment which could be safely used by
non-clinical staff with minimal explanation or training.
•
Up-to-date equipment for wart treatment which minimises hazardous substance handling
requirements.
Videoconferencing facilities of a standard appropriate for remote ‘telehealth’ clinical work be
installed and relevant staff trained in their use in the clinical rooms at Ashley and also at locations
readily accessible to the Ashley general practitioner. These locations are to be agreed with the GP
and which could be at their home and work, depending on the role they are able to undertake within
the 24 hours per day, 7 days per week, 365 days per year clinical support model being implemented
(ST).
Clinical Governance
We recommend that:
13
Clinical governance be strengthened by the regular and routine use of videoconferencing,
face-to-face and other communication to ensure review of clinical care and outcomes through:
13.1 Access to remote clinical support and communication through arrangement with Correctional
Health clinical staff at Risdon Prison (ST after installation of videoconferencing facilities).
13.2 Scoring health risk assessments at entry and exit (except where this is not achievable due to
legal process) to demonstrate the impact of education, clinical care and other interventions
whilst in Ashley (ST).
13.3 Undertaking regular audits of clinical documentation including admission health risk
assessments to ensure that good practice is maintained (ST).
13.4 Weekly Case Management Progress Meetings be continued, with participation by Ashley
nursing and medical staff as well as by relevant staff from Correctional Primary Health Service
(ST after installation of videoconferencing facilities).
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Recommendations A
13.5 At these meetings there will also be review on a regular basis of activity data, workload levels,
any adverse clinical events, data from clinical risk assessments audit of clinical documentation
completion and improvements therein, planning of prevention and health risk improvement
activities and any other matters of clinical concern (ST).
13.6 A quarterly meeting between the Ashley senior clinical staff and Ashley management to review
the activity and performance of the clinical services, for any party to raise any issues of
concern and monitor implementation and impact of the recommendations which have been
accepted for implementation (ST and LT).
Clinical Staffing
We recommend that:
14
Clinical Staffing arrangements at Ashley be enhanced by:
14.1 Maintaining the full-time CNC arrangements, noting that this role fulfils CNC as well as AN
roles (ST).
14.2 Clarifying and communicating to staff the CNC and Ashley Nurse (AN) roles (ST).
14.3 Adding 0.8 FTE Registered Nurse (RN) Level 2 to extend the AN role. This may be two
0.4 FTE positions to allow for increased staffing flexibility and more sustainable on-call cover
(ST).
This is recommended in order to:
○
provide seven-day per week on-site nursing cover (9-5)
○
support an after hours on-call roster
○
ensure two-day per week overlap to allow CNC to undertake Management tasks, case
conferencing/clinical governance/professional development/handover sessions with GP
and CNC/RN team and allow CNC to provide health education sessions for youths
○
provide for succession planning and
○
contribute to leave relief arrangements for the CNC.
14.4 Enhancing the existing visiting general practitioner arrangements to include time allocated for
clinical governance and professional development activities (ST).
14.5 Entering into reliable arrangements with other organisations to provide cover for planned
medical and nursing staff leave and contingency plans for unplanned leave (eg sick leave) for
which cover cannot be planned or managed within the additional resources recommended
(ST).
14.6 Confirm appropriate on-call arrangements for the Ashley nurse role (ST).
14.7 Assessing the need for additional medical clinical time after the new 24 hours per day, 7 days
per week, 365 days per year arrangements have been implemented and achieved a steady state
– or earlier if necessary (LT).
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Recommendations A
Staff Development and Training
We recommend that:
15
Professional development of clinical staff be actively supported by:
15.1 Appropriate orientation and training support at the point of initial employment of any new
clinical staff to facilitate their practice in this setting. This can include accessing experience and
training at the Correctional primary health service at Risdon Prison (ST).
15.2 A professional development plan for each clinical staff member in line with their specific
needs (ST).
15.3 An annual allocation of funding for this which is commensurate with the development needs
of the individual required for them to perform their roles to an appropriate standard which
are a consequence of the unique clinical setting (ST).
15.4 Opportunities for clinical staff rotation with the Correctional Primary Health Services at
Risdon Prison for the mutual benefit of each service (ST).
15.5 Subscriptions for ongoing online access to relevant clinical knowledge resources
(Murtagh's General Practice, Therapeutic Guidelines and others relevant to the clinical setting
and which are not already available via the existing DHHS EPOCH knowledge access system)
(ST).
16
Certified first aid training equivalent to level 2 be continued for all Ashley custodial staff and
maintained by refresher training at the recommended frequency (ST and LT).
17
Assess the need for resuscitation further training equivalent to advanced level 3 (ST for
assessment and LT for implementation if it is assessed as required).
Implementation
We recommend that:
18
To ensure timely and successful implementation of recommendations accepted by the Minister:
18.1 Establish a small Steering Committee to provide implementation project governance which
includes senior clinician and management representation and is chaired by the Manager
Custodial Youth Justice and this Steering Committee will provide progress reports to the
Ashley Advisory Committee.
18.2 Provide a suitably senior and experienced implementation project support officer to assist with
implementation and whose first task after appointment will be to develop an implementation
project plan in consultation with relevant stakeholders. This may be through secondment of a
suitably senior Ashley staff member.
18.3 Make additional funding available for Ashley to a level commensurate with the requirements of
the recommendations and the other support necessary for them to successfully and sustainably
be implemented without compromising the activities already undertaken at Ashley.
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Glossary A
Glossary
ACHS
Australian Council on Healthcare Standards
AGPAL
Australian General Practice Accreditation Limited
AN
Ashley Nurse
CAT
Clinical Assessment Team
CHO
Chief Health Officer
CPHS
Correctional Primary Health Service at Risdon Prison
CNC
Clinical Nurse Consultant
DHHS
Department of Health and Human Services
LT
Longer-term
PHP
Prison Health Pro
RACGP
Royal Australasian College of General Practitioners http://www.racgp.org.au/
SOP
Standard Operating Procedures
ST
Shorter-term
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Appendix A
Appendix
Appendix A: Terms of reference
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Appendix A
Department of Health and Human Services
Terms of Reference for Team Undertaking Clinical Assessment of the
current Ashley Youth Detention Centre’s Policy and Protocols for Health
Issues
Background
The Minister for Children (Minister) has requested that the Chief Health Officer (CHO) undertakes a
clinical assessment (CA) of the current Ashley Youth Detention Centre’s (Ashley) policy and protocols for
health issues.
This has been commissioned by the Minister following a death at Ashley on Monday, 25 October 2010 in
recognition of her concern to have appropriate arrangements in place for the health and wellbeing of
detainees there.
Purpose
The CHO will provide a written report to the Minister, as soon as possible, but no later than by the end of
November 2010, for her to be informed about:
•
the suitability and appropriateness of Ashley’s policy and protocols for health issues
•
recommendations for their improvement and
•
any other observations which are not directly relevant to this assessment but which may be helpful
for the investigation of the events leading to the recent death at Ashley.
Role and Function
The clinical assessment team (CAT) will examine the available evidence of policy and protocols in place at
Ashley for dealing there with health issues of the detainees. This will include review of the:
•
documents provided by Ashley staff/management
•
facilities at Ashley which are used for health service provision
•
clinical arrangements in place for health risk assessment and response and
•
clinical governance arrangements.
The report will comment on these, make recommendations for their improvement (if appropriate) in
relation to the provision of health services and include other observations that the CAT considers may be
helpful to the investigation of events leading to the recent death.
The clinical assessment will not examine the facts or circumstances of the death on 25 October 2010 as
these are properly the subject of Coronial investigation and of follow up under the DHHS serious incident
policy.
The CAT will prepare a report for presentation to the Minister as soon as possible but no later than the
end of November 2010.
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Appendix A
Membership of the Clinical Assessment Team
Lead:
Dr Craig White, Chief Health Officer
Membership:
Dr George Cerchez, Director Medical Integration and Workforce
Gina Butler, Director of Nursing Safety and Quality
Dr Chris Wake, Clinical Director, Primary Health Care Correctional Services
Members of the Clinical Assessment Team (CAT), as named in these terms of reference, will be deemed
appointed by virtue of the Minister endorsing these terms of reference.
Members have been chosen for the relevance of their individual experience and expertise to the setting of
this clinical assessment and their ability to undertake the task.
The CAT will conclude upon delivery of their report to the Minister.
Member Roles
•
The CHO, as CAT lead, will - with the assistance, as appropriate of other members and their
support staff:
○
ensure the Terms of Reference are met
○
identify the need for and seek expert advice where appropriate
○
identify and liaise with relevant people from whom information is required to support the
review
○
obtain relevant information
○
undertake site visit(s) to Ashley
○
prepare the report and
○
provide the report to the Minister.
•
All members will give the review appropriate priority.
•
Members will remain available to assist as required following conclusion the work of the CAT.
Meeting Times
A site visit to Ashley is scheduled for Thursday, 4 November 2010 following discussions on
Thursday, 28 October 2010 with Mark Byrne.
Other CAT interactions will take place flexibly in support of the timeframes. Meetings and other
interaction can take place by meeting in person, telephone contact, via email or videoconferencing.
Meeting Protocols
•
The CAT will convene as early and as frequently, in person, via email and telephone as required to
complete this task.
•
There is no requirement for a quorum.
•
Administrative support will be provided as required by DHHS staff within the work areas of the CAT
members.
•
There is no arrangement for proxies.
•
Documentation will be undertaken as required in support of the work of the CAT
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Appendix A
Review of Terms of Reference
They can be amended during their currency with the agreement of the Minister.
These terms of reference will lapse at the time the report to the Minister is completed.
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Attachments
Attachments
Attachment 1: Documents provided for review to the Clinical Assessment Team:
•
Selection of the Standard Operating Procedures (SOP) relevant to the clinical assessment,
numbers:
SOP 1
SOP 4
SOP 11
SOP 13
SOP 20
SOP 21
SOP 22
SOP 28
SOP 29
SOP 31
SOP 32
•
Best Practice Guidelines for Assistance with Administration of Medication by and to Young
Persons and Management of Medication
•
Client Assessment Tool
•
SECAPS Assessment Tool (Secure Care Psychosocial Screening)
•
HB Unit – Nurse/GP Assessment Form
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References
References
Youth Justice Act 1997 Part 6 – Detention Centres
http://www.thelaw.tas.gov.au/tocview/index.w3p;cond=;doc_id=81%2B%2B1997%2BAT%40EN%2B2008082
0120000;histon=;prompt=;rec=;term= accessed 24 November 2010
i
DHHS website
http://www.dhhs.tas.gov.au/about_the_department/organisational_structure/operational_units/dcyfs/unit_st
ructure/area_teams/youth_justice_services accessed 24 November 2010
ii
Australasian Juvenile Justice Administrators Standards for Juvenile Custodial Facilities, Revised Edition,
March 1999 http://www.djj.nsw.gov.au/pdf_htm/publications/general/Finalstandards.pdf accessed 24
November 2010
iii
RACGP Standards for General Practices 4th Edition
http://www.racgp.org.au/Content/NavigationMenu/PracticeSupport/StandardsforGeneralPractices/Standards
4thEdition.pdf accessed 24 November 2010
iv
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