A peak Tasmanian advocacy group has likened the Roy Fagan Centre to a prison based upon insights provided by its clients.
The centre, which has been subject to numerous coronial inquests, this week received a damning assessment from the state's chief psychologist following an event on Christmas Day.
The family of an elderly dementia patient at the Hobart centre were shocked to find the 78-year-old man with a maggot-infested wound on his leg during a visit.
The government-commissioned chief psychologist Aaron Groves to do a report on the incident which was released this week.
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He found the Roy Fagan Centre was out of date and inadequate for some of the people who were admitted to the facility.
Dr Groves found there was an insufficient number and type of nursing staff for the variety and complexity of patient needs.
He said there was an overall significant deficit in allied health staff at the hospital which had a significant impact on the level of care provided in the units.
Advocacy Tasmania chief executive Leanne Groombridge said clients had painted a bleak picture to the service of what the Roy Fagan Centre was like.
"They've told us of feeling unsafe and being locked in their rooms," she said.
"They say they can be held there for months, sometimes years, and that doctors' visits are infrequent.
"Our clients tell us that is like living in an institution with the hallways, common areas and rooms lacking any kind of stimulation and few activities.
"They say it is more reminiscent of a prison than a leading mental health hospital.
"The mental toll and despair that an admission to the centre can cause is very apparent and clients report significant decreases in their mental wellbeing."
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A state's coroners court has undertaken a number of inquiries into deaths connected with the Roy Fagan Centre with concerns from family about care provided to their loved ones a theme during the investigations.
Cherl Weily's father Richard was the subject of one such inquiry following his death in 2013.
Mr Weily had been admitted to the centre three weeks after admission into a standard aged care facility, due to worsening conditions associated with dementia and Parkinson's disease.
Ms Weily said he was placed on medication while he was at the Roy Fagan Centre which seemed to improve his wellbeing, though had a side effect of increased risks of falls.
She said the night before he was due to be released from the centre, he fell.
Ms Weily said a nurse from another ward checked on him while he was in bed, however, an ambulance was not called until about eight hours after the fall.
Mr Weily was found to have fractured his hip and died six days later in the Royal Hobart Hospital from what the coroner described as probable pneumonia.
The inquest found a fall risk assessment had not been done on Mr Weily until nine days after his admission to the Roy Fagan Centre.
Ms Weily said her father had been moved to the centre without consultation with herself or her sister even though they held power of attorney and guardianship rights.
She said the relay of communication over his care and condition while at the centre was lacking.
Ms Weily said she hoped to see the government commit to timelines to satisfy the recommendations in the latest report on the Roy Fagan Centre, backed by accountability benchmarks.
"With this new report, we have a chance for real change," she said.
Dr Groves in his report said many connected to the centre had been shocked at what had occurred to the unnamed 78-year-old man last Christmas Day.
"It was, at times, a very difficult investigation," he said.
"People's sense of pride in their service had given way to a deep sense of shame.
"There is no doubt the [centre] has had problems in the past.
"These have been recognised and significant changes have been made in the quest for improvement.
"The RFC has, however, a significant path ahead of them to achieve the quality of care that they aspire to deliver and that the community expects."
Australian Nursing and Midwifery Federation state executive director Andrew Brakey said staff at the Roy Fagan Centre had told Dr Groves they had asked over a long period of time for more resources to better carry out their duties, but nothing had been done.
"It had even fallen on deaf ears or the governance processes were not in place to ensure that those concerns were heard and dealt with," he said.
Dr Groves' report noted a lack of investment and planning into older persons mental health services.
Mr Brakey said this was not specific to the Roy Fagan Centre, but the state in general.
"At the moment we know that there are already hundreds of nursing vacancies across the state and specifically in older people's mental health where you need specialised staff," he said.
"We don't have the specialised staff in Tasmania to fill those gaps."
Council on the Ageing Tasmania chief executive Sue Leitch said whether the Roy Fagan Centre was fit-for-purpose was an ongoing concern for the organisation.
"The report has highlighted that models of care need review and we would welcome the opportunity to work with other community sector organisations to have input into this from the perspective of older people and their friends and family who may be caring for them," she said.
"How people are admitted to facilities and discharged from facilities is always an area that needs attention.
"We need to be clear that these are well explained to people and that their wishes are listened to and that this leads to receiving high-quality care in a safe and caring environment."
The government last month tabled amendments in Parliament to the state's Guardianship and Administration Amendment Act in relation to care directives.
Ms Groombridge said clients who found themselves admitted to the Roy Fagan Centre were at a loss to explain how they ended up there.
"Often clients ask us to find out who has authorised the decision made on their behalf, frequently with no consultation with the actual person or their loved ones," she said. "They are often found to have been placed on emergency guardianship orders after a short hospital admission.
"The guardianship system is urgently in need of a complete overhaul so that the primary focus is on the individual whose life is significantly affected by decisions made on their behalf.
"Rules regarding the evidentiary basis for an emergency application for guardianship or administration and the approvals of such orders must be urgently reviewed."
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