The standard of care at Roy Fagan Centre "did not meet standards or expectations" of the Tasmanian Health Department, an independent review has found.
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The state-run mental health centre made headlines in December after it was revealed an elderly patient was left with a maggot-infested wound, found by his daughter on Christmas Day.
Thirteen findings and six recommendations have been put forward in the review, all of which the Tasmanian Government has accepted.
The findings included that the standard of care provided to the resident in the 24 hours before Christmas Day in 2020 was "well below an acceptable level", and that there was an "overall significant deficit" in Allied Health Staff at the Roy Fagan Centre, resulting in a "major significant negative impact of the level of care provided in these units".
Health Minister Jeremy Rockliff "unreservedly" apologised to the family on behalf of the government for the "distress and traumatic events" that occurred.
"Greater efforts should have been made at that time to better meet the patients needs," Mr Rockliff said.
"I would like to stress that what occurred is not a reflection on any of the staff working at the Roy Fagan Centre."
The review found that a combination of factors led to this incident occurring, including an insufficient number and type of nursing staff for the variety and complexity of patient need.
The findings also stated the facility was "both out of date and inadequate for some of the people are admitted to the facility", increasing risk to patients.
However, it found the Roy Fagan Centre was 'well placed' to embrace change and improvement, and found the patient care for the resident at the heart of the review was satisfactory for the rest of his admission.
Mr Rockliff said the clinical leadership team at the facility, once aware of the issue, "acted immediately" and had already made changes to process and procedures to prevent an incident such as this from occurring again.
He said, with the recommendations put forward in this review and the improvements already made, he was "confident" that this would be a stand-alone incident.
The recommendations put forward from the report include a call for Older People's Mental Health Services to be a statewide program within Statewide Mental Health Services with its own dedicated leadership, and for the OPMHS to develop a comprehensive system of Clinical Governance with dedicated resources to support this function.
Mr Rockliff did not provide a timeline or specific budget for these recommendations, but said all would be supported by the government.
"This happened on my watch, and I have to take that responsibility as minister, and my responsibility moving forward is to ensure that all the recommendations are implemented."
The Australian Medical Association Tasmania on Tuesday responded to the release of the report.
Vice-president Dr John Saul said what is key is that lessons are learned "at all levels of government" in regards to how this incident could occur.
"The report makes it clear that there is a need for more nursing and allied health staff to keep the quality of care at the level every Tasmanian should expect for themselves or their family requiring the care of the Roy Fagan Centre", Dr Saul said.
"AMA Tasmania supports the six recommendations in the report, which offer a constructive way forward to strengthen services for older persons.
"What is clear is that additional resources to employ more staff with specialist skills in caring for older people with mental health issues are required to meet increasing demand for these services and ensuring quality care can be provided at all times."