Executive summary

The investigation

In 2017, the Queensland Ombudsman received information that raised concerns about the treatment of people detained at the Forensic Disability Service (FDS).

The FDS is a medium secure 10-bed facility situated at Wacol, Brisbane, for the involuntary detention of people found unfit for trial as a result of an intellectual or cognitive disability, and who require secure care. The facility is operated by the Department of Communities, Disability Services and Seniors (the Department) with oversight from the Director of Forensic Disability (the Director).

Two reports delivered to the Queensland Government in 2006 found that people with intellectual and cognitive disability were being detained in secure mental health facilities as a result of a lack of alternative legislative and service arrangements. The seminal report by the Honourable William J Carter QC, Challenging Behaviour and Disability: A Targeted Response (the Carter report), recommended that people with intellectual or cognitive disability who interact with the criminal justice system required a different and specialised response. As part of the Queensland Government’s response to these reports, the Forensic Disability Act 2011 (the FD Act) was enacted and the FDS was established in July 2011.

Initial inquiries by the Office of the Queensland Ombudsman confirmed that government and non-government entities had raised concerns about the treatment of people detained at the FDS, and the length of their detention periods. Given the gravity of these concerns, the Ombudsman decided to commence an investigation into the treatment of people within the forensic disability system in Queensland. The investigation commenced on 15 May 2018.

At first, the scope of the investigation was to encompass issues facing the broader forensic disability system. However, based on information obtained during the early phase of the investigation, the scope was refined to whether people detained at the FDS were receiving appropriate care and support in compliance with the FD Act.

The FD Act provides for the involuntary detention, care, support and protection of people with intellectual or cognitive disability at the FDS. This legislation embeds key concepts of the Convention on the Rights of Persons with Disabilities, an international human rights treaty, into local legislation that applies at the FDS. The FD Act therefore transforms international human rights objectives into specific legal requirements that must be applied. Guiding principles that recognise the human rights of people detained, and which promote therapeutic outcomes, are incorporated into the legislative scheme, and are also embedded in specific provisions.

Knowledge of concerns

The issues outlined in this report are not new. By the time this investigation commenced, the Department had already generated or received much of the information contained in this report. In fact, the Department has regularly been informed about key issues of concern over the course of several years.

In April 2017, the Department produced a draft bill in response to the statutory requirements to review the FD Act. A consultation draft of this bill was provided to stakeholders for comment.

The Public Guardian’s submission to the draft bill raised specific concerns about the treatment of people detained at the FDS and provided specific case examples. In response, the Department appointed an interstate clinician to carry out an investigation into the allegations. The investigation found that three allegations were substantiated, two were partially substantiated and 11 were unsubstantiated. However, outside the prescribed terms of reference, the appointed clinician included general observations that identified significant weaknesses in the operation of the FDS.

The Department then commissioned a second review in partnership with Queensland Health. Professor James RP Ogloff AM, Dr Janet Ruffles and Dr Danny Sullivan, acting for the Centre for Forensic Behavioural Science, Swinburne University of Technology, delivered their report in March 2018 (the Ogloff report). The Ogloff report recommended significant reform to the current forensic disability system in Queensland, and was tabled in parliament during the course of the Ombudsman’s investigation in October 2018.

By September 2016, after the FDS had been in operation for more than five years, no person detained at the FDS had been transitioned out of the facility. This triggered a safeguard provision under the FD Act that requires the Director to review a person’s detention to determine if they will continue to benefit from the care and support provided by the FDS (referred to in this report as the 5-year reviews).

Six of the Director’s 5-year review reports found that the person detained was not expected to benefit from further detention. Two further 5-year review reports found that the person had not benefited from detention at the FDS. The Director provided these reports to the Department.

Since 2014, the Office of the Director has also undertaken audits to assess legislative compliance with the FD Act and to monitor clinical domains that fall within the Director’s legislative responsibilities. The Director’s audit reports, which were provided to the Department, uncovered widespread legislative non-compliance across key areas of the FDS, including across areas linked to the treatment and support of people detained at the FDS.

Key issues

Within a closed environment that detains people with intellectual and cognitive disabilities, legislative compliance is critical to safeguarding the rights of those detained. However, this investigation found that widespread legislative non-compliance has been an enduring issue since the FDS was established.

Building blocks of good administrative practices not met

The FDS’s approach to recordkeeping has not met required standards. This has impacted on the management of risks within a complex environment, and has impacted on the quality of care and support for people detained. The absence of records, paucity of detail, and incomplete or inaccurate content also impacted on the capacity of the investigation to review all aspects of legislative compliance. Some records inspected by the investigation were so poor they undermined the capacity of the FDS to demonstrate the basic level of competence required to administer its legislative functions.

Records and recordkeeping are particularly important in this context. The quality of recordkeeping at the FDS undermined the credibility of the organisation and exposed the people detained at the FDS, its staff and the community to risk.

The investigation identified the lack of an effective and integrated policy framework that supports the FDS to achieve legislative compliance and strategic objectives. This has led to inconsistencies between policies and procedures, as well as confusion around their application.

Concerns with the care and support of people detained

A primary focus of the FDS is to provide evidence-based programs that maximise a detained person’s quality of life, reduce the risk of reoffending and increase opportunities for community participation and reintegration, while also ensuring the safety of the community. The FDS was therefore expected to deliver programs specifically designed to meet the needs of people with intellectual and cognitive disability, and to thereby promote a therapeutic, rights-based approach.

Individual development plans must be prepared for every person detained at the FDS. However, individual development plans were found not to meet minimum legislative requirements, particularly in regard to the standard and quality of care. While the standard of individual development plans has improved, deficiencies have had significant impacts on the lived experience of people detained.

The investigation found that the FDS has failed to deliver programs to adequately promote the development, habilitation, rehabilitation and quality of life of people detained. This has impacted on their reintegration into the community, a key objective of the FD Act.

Concerns about risk management plans, which must be in place for each person detained, were also identified.

Detention periods and delays in transition

Although the FD Act contains a legislative obligation to ensure that all detained people have a transition plan in place, the investigation found that transition plans were not developed until 2017, six years after commencement of the FDS. This adversely impacted on the transition of people detained.

Regulated behaviour controls

Regulated behaviour controls, commonly referred to as restrictive practices, can be used at the FDS in limited and prescribed circumstances, and only as a last resort. The FD Act requires that a regulated behaviour control must only occur in a way that has regard to the human rights of the detained person, aims to eliminate the need for its use, and ensures transparency and accountability.

One of the most concerning findings of this investigation was that the FDS had not complied with legislation that restricts the use of regulated behaviour controls.

The FDS is required to keep a register of the use of regulated behaviour controls, a key component of the FD Act’s transparency and accountability regime. However, the investigation found that an operable and effective register was not created until 2016, and that, since then, the register contained inaccuracies and was therefore unreliable.

Given the importance of ensuring that medication prescribed for health care was not administered in circumstances that could amount to behaviour control, this issue was also investigated. The FDS was unable to demonstrate compliance with mandatory legislative provisions restricting the use of behaviour control medication at the FDS.

One person detained at the FDS, referred to as ‘Adrian’ in this report, has been subjected to back-to-back three-hour seclusion orders for more than six years. On 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.

The circumstances of Adrian’s case are severe and concerning, and were widely known to the Director and the Department. The Director’s 5-year review suggests that the impact of this seclusion on Adrian has been significantly detrimental to his health and wellbeing.

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.

Police attendance and criminal charges

The investigation also found that the FDS has requested assistance from the Queensland Police Service (QPS) to respond to situations involving Adrian. The investigation found that police have attended with police dogs, and that in some of these circumstances, this was likely for the purpose of controlling Adrian’s behaviour.

Some people detained at the FDS have been charged with criminal offences for incidents that have occurred between the person detained and FDS staff. All charges brought by the QPS in this context have been discharged by a court on the basis that the person was permanently unfit for trial as a result of the person’s intellectual or cognitive disability. The investigation concluded that some people detained at the FDS have been exposed to criminalisation on the basis of their disability.

Recent developments

Human Rights Act 2019

This investigation was completed prior to the enactment of the Human Rights Act 2019 (HR Act). The HR Act makes it unlawful for a public entity to act in a way that is incompatible with human rights, for example, by failing to give proper consideration to human rights when making decisions.

The application of the HR Act at the FDS will add an additional layer of protections to those that already exist under the FD Act.

New appointments

The persons who occupied the roles of Director and Administrator during the conduct of the investigation were not in those roles as at 1 July 2019. The current Director and Administrator are not the persons referred to in this report.

Causes and conclusions

Contributing factors and indicators

The investigation found a range of system-wide issues had contributed to administrative and operational failures of the FDS. These included that:

  • The FDS has not embedded an appropriate and evidence-based approach to behaviour management
  • There has been a lack of ongoing clinical expertise at the FDS
  • There has not been a consistent, comprehensive and structured approach to the delivery of healthcare services
  • There has not been a consistent whole-of-service approach to working with Aboriginal and Torres Strait Islander peoples, families and communities
  • Despite the high proportion of people detained at the FDS who have a reported history of childhood trauma, approaches to trauma-informed care have not been appropriately considered, implemented or prioritised at the FDS.

Governance and oversight structures

The FDS is operated by the Department with oversight from the Director. Despite clear statutory obligations under the FD Act, the responsibilities of the Department and the Director in the operation of the FDS have not been mutually understood or consistently applied since its commencement.

One of the key themes that emerged throughout the investigation was the Department’s expanding and contracting characterisation of its role in the operation of the FDS, and this was reinforced in responses to the Ombudsman’s proposed report. The investigation found persistent disagreement between the Department and the Director about their respective roles and responsibilities in administering the FDS.

The investigation also found that organisational arrangements imposed by the Department did not give effect to the independence of the position of Director, and concluded that administrative decisions of the Department over time have impacted on the capacity of the Director to discharge their statutory obligations under the FD Act.

Opinions

Opinions

Under s 49 of the Ombudsman Act 2001, I form the following opinions:

Opinion 1

1.1 The policy framework in place at the FDS has failed to integrate organisational and operational procedures issued by the Department and the FDS with policies and procedures issued by the Director about the detention, care, support and protection of people detained at the FDS.

1.2 This led to:

  • Inconsistencies and a lack of synthesis of policies and procedures
  • Staff confusion around the application of the policies and procedures.

1.3 Policies issued by the Director about the detention, care, support and protection of people detained at the FDS are not publicly available.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 2

2.1 The information management system in place at the FDS is ineffective in meeting its legislative requirements.

2.2 The approach to recordkeeping at the FDS has not met standards imposed by the Public Records Act 2002.

2.3 This has:

  • potential impacts on the quality of care and support provided to people detained at the FDS
  • reduced the transparency and accountability of the FDS
  • in some circumstances, created a risk to the safety of the people detained at the FDS, its staff and the community.

This is administrative action that is unreasonable for the purposes of 49(2)(b) of the Ombudsman Act.

Opinion 3

3.1 Individual development plans (IDPs) for people detained at the FDS have not met all legislative requirements imposed by the Forensic Disability Act 2011 (FD Act).

This is administrative action that is contrary to law for the purposes of s 49(2)(a) of the Ombudsman Act.

3.2 From the date of commencement of the FDS to February 2018, the FDS’s approach to developing and maintaining IDPs has failed to operationalise s 13(1) of the FD Act, which provides that IDPs are designed:

  • to promote development, habilitation and rehabilitation of the person detained
  • to provide for the care and support of the person detained
  • when appropriate, to support the person’s reintegration into the community.

This failure has impacted the level of care and support provided to people detained at the FDS.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 4

4.1 Rehabilitative and habilitative programs of sufficient frequency or quality have not been delivered to people detained at the FDS.

4.2 The lack of sufficient and appropriate programs has not:

  • adequately promoted the development, habilitation, rehabilitation and quality of life of people detained
  • made a timely impact on reducing the risk profile of people detained
  • supported reintegration into the community as intended by s 15(1)(a)(iii) of the FD Act.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 5

5.1 Legislative requirements established by s 20 of the FD Act with regard to authorising limited community treatment (LCT) have not been consistently applied at the FDS.

This is administrative action that is contrary to law for the purposes of s 49(2)(a) of the Ombudsman Act.

5.2 Two people detained at the FDS have had very limited access to LCT. In those cases, the FDS has not demonstrated that LCT opportunities have been regularly considered.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 6

6.1 A comprehensive and integrated approach to risk management for people detained at the FDS has not been developed, implemented or applied at the FDS.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 7

7.1 The FDS did not have a register of the use of regulated behaviour controls (regulated behaviour control register) as required by s 74 of the FD Act until 2016.

7.2 Since commencement of the current regulated behaviour control register in 2016, accurate details about the use of regulated behaviour controls at the FDS have not always been recorded in the register, as required by the Forensic Disability Regulation 2011.

This is administrative action that is contrary to law for the purposes of s 49(2)(a) of the Ombudsman Act.

7.3 The Director’s current approach to public reporting does not adequately address transparency and accountability in the use of regulated behaviour controls at the FDS, as required by s 42(b)(iii) of the FD Act.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 8

8.1 PRN medication may have been administered to people detained at the FDS for the purpose of behaviour control.

8.2 The FDS was unable to demonstrate compliance with mandatory legislative provisions safeguarding behaviour control medication at the FDS.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 9

9.1 Seclusion has been used for people detained at the FDS as a regulated behaviour control where appropriate approaches to behaviour support have not been effectively adopted or implemented. This is not consistent with s 42 of the FD Act.

This is administrative action that is contrary to law for the purposes of s 49(2)(a) of the Ombudsman Act.

9.2 In relation to decisions to seclude Adrian:

  • The FDS has failed to demonstrate that all decisions made to seclude Adrian were made in accordance with the requirements of ss 61–63 of the FD Act.This is administrative action that is contrary to law for the purposes of s 49(2)(a) of the Ombudsman Act.
  • The seclusion of Adrian amounts to permanent seclusion.
    This is administrative action that is oppressive for the purposes of s 49(2)(b) of the Ombudsman Act.
  • The FDS has failed to comply with requirements to record and retain CCTV footage as required by relevant legislation and policies.
    This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.
  • The permanent seclusion of Adrian has resulted in a deterioration of his condition and has significantly impacted on his quality of life and human rights.

This is administrative action that is unreasonable, oppress and improperly discriminatory for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 10

10.1 Despite all charges brought by the QPS against people detained at the FDS, subsequent to their admission, having been discharged by a court as a consequence of the person’s intellectual or cognitive disability, there has been no appropriate review of incidents that gave rise to those charges, or identification of systemic issues that may have contributed or improvements in service delivery.

10.2 People detained at the FDS have been exposed to criminalisation on the basis of their intellectual and cognitive disability.

10.3 The FDS did not adequately investigate the complaint made by a person detained at the FDS involving an alleged assault by an FDS staff member.

10.4 In some circumstances, the FDS appears to have requested assistance from the QPS in the management of Adrian that amounted to behaviour control.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 11

11.1 Between the commencement of the FDS and 2017, no IDPs contained a transition plan as required under s 15(1)(b) of the FD Act.

This is administrative action that was contrary to law for the purposes of s 49(2)(a) of the Ombudsman Act.

11.2 When implemented, transition plans were deficient and ineffective in meeting their prescribed purpose.

11.3 The failure to create and maintain a transition plan of appropriate quality for each person detained at the FDS may have led to unnecessary detention.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

11.4 There is no mechanism to resolve a lack of agreement between the Director and the Chief Psychiatrist to transition a person from the FDS to an authorised mental health service.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 12

12.1 The Department and the Director have not clarified the nature and extent of the FDS’s responsibility for one person for whom the FDS is responsible but who is not detained at the FDS.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 13

13.1 There has not been a consistent, comprehensive and structured approach to the delivery of healthcare services to people detained at the FDS.

13.2 There has not been a consistent, integrated and sufficient approach to providing culturally appropriate care to those detained at the FDS who identify as Aboriginal and Torres Strait Islander people.

13.3 There has not been a whole-of-service approach to the consideration and implementation of principles of trauma-informed care.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 14

14.1 The workplace culture of the FDS does not promote the effective achievement of its purpose and key roles.

14.2 The FDS has not had any complaints management system in place to identify, assess and respond to complaints by or on behalf of people detained at the FDS.

14.3 The FDS has not maintained a conflicts of interest register.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Opinion 15

15.1 The Department’s administrative arrangements have hindered the Director’s ability to effectively undertake the statutory functions imposed by ss 87–89 of the FD Act.

15.2 The Director’s attempts to facilitate the proper and efficient administration of the FD Act as required by s 87(1)c) of the FD Act were ineffective.

15.3 The Director’s discharge of the statutory function of ensuring the protection of the rights of people detained at the FDS as imposed by s 87(1)(a) of the FD Act has been limited.

This is administrative action that is unreasonable for the purposes of s 49(2)(b) of the Ombudsman Act.

Recommendations

Under s 50 of the Ombudsman Act 2001, I make the following recommendations:2

Recommendation 1

That the Director-General, in consultation with the Director:

1.1 Undertakes a review of all policies and procedures in operation at the FDS.

1.2 Implements a cohesive, comprehensive and integrated policy framework.

1.3 Ensures all FDS staff are appropriately trained to apply all policies and procedures.

That the Director:

1.4 Ensures that policies about detention, care, support and protection of people detained at the FDS are made publicly available.

Recommendation 2

That the Director-General, in consultation with the Director:

2.1 Ensures that full and accurate records about all administrative decisions made under the FD Act at the FDS are created and maintained.

2.2 Develops and implements an effective electronic record management system at the FDS that ensures:

  • decisions made under the FD Act are appropriately recorded; and
  • those records can be effectively and accurately accessed, managed and retrieved.

2.3 Ensures information contained in FDS records is available to inform improvements in service delivery.

That the Director:

2.4 Pursuant to s 91 of the FD Act, issues a policy and procedure that ensures records about the detention, care and support of people detained at the FDS adequately protects their rights and interests.

2.5 Audits and reports on compliance by the FDS with relevant recordkeeping standards at least annually.

2 For the purposes of Part 6, Division 1 of the Ombudsman Act 2001.

Recommendation 3

That the Director:

3.1 Reviews all IDPs in place at the FDS.

3.2 Ensures that all IDPs demonstrate full legislative compliance, including regular review.

3.3 Ensures that all IDPs operationalise s 13(1) of the FD Act, and are consistent with a contemporary, evidence-based approach to positive behaviour support plans.

3.4 Ensures that IDPs consolidate all existing plans and reports into a single, consistent and comprehensive document easily accessible by all relevant staff.

3.5 Reports, at least annually, on whether IDPs reflect improvements in service delivery to people detained at the FDS.

Recommendation 4

That the Director:

4.1 Reviews the adequacy, appropriateness and quality of programs delivered to people detained at the FDS, and makes recommendations to the Director-General for implementation.

That the Director-General, in consultation with the Director:

4.2 Reviews the staffing profile of the FDS to ensure it has the capacity to manage, implement and deliver appropriate evidence-based programs within a forensic disability setting to an acceptable standard.

Recommendation 5

That the Director:

5.1 Reviews the FDS’s approach to authorising LCT to ensure that each decision about LCT assesses and responds to all relevant considerations imposed by s 20 of the FD Act, as well as relevant policies and procedures.

5.2 Regularly audits and reports on the FDS’s compliance with s 20(3)(a) of the FD Act in relation to decisions to authorise LCT.

5.3 Where a court or tribunal has authorised LCT, continues to audit and report on whether the FDS regularly undertakes a fresh consideration of whether LCT should be authorised. Where a decision is made not to authorise LCT for a person detained, ensures the reasons for that decision are appropriately recorded.

Recommendation 6

That the Director-General, in consultation with the Director:

6.1 Develops and implements an appropriate and evidence-based risk management framework for people detained at the FDS.

6.2 Provides appropriate training to all staff required to use the risk management framework.

Recommendation 7

That the Director-General, in consultation with the Director:

7.1 Ensures that the FDS’s regulated behaviour control register is accurately maintained.

7.2 Arranges for the Public Guardian and the Public Advocate to have regular access to the FDS’s regulated behaviour control register.

That the Director:

7.3 Publicly reports on all use of regulated behaviour controls at the FDS at least annually.

Recommendation 8

That the Director-General, in consultation with the Director:

8.1 Implements all recommendations of the Medication report, and regularly audits compliance with the FD Act and other relevant legislation as they relate to the use of medication at the FDS.

That the Director:

8.2 Arranges medication reviews for all people detained at the FDS by an independent psychiatrist and pharmacist, and undertakes reviews of medication as clinically directed thereafter.

8.3 Provides training for all FDS management and staff in relation to the administration of all medications, including behaviour control medication.

Recommendation 9

That the Director:

9.1 Reviews the clinical management of Adrian and makes recommendations with a view to reducing the use of seclusion and improving his quality of life.

9.2 Develops and recommends a service-wide approach to behaviour support across the FDS with a view to reducing the use of regulated behaviour control in accordance with s 42(b)(iii) of the FD Act.

9.3 Reviews the FDS’s use of seclusion in line with legislative obligations imposed by the FD Act, particularly ss 61–63.

9.4 Reviews the FDS’s management of CCTV images and makes recommendations with a view to ensuring compliance with relevant legislation and policies.

Recommendation 10

That the Director-General, in consultation with the Director:

10.1 Develops policies and procedures about the scope and application of circumstances when the QPS should be called to attend the FDS.

10.2 Ensures that any charges brought by the QPS against a person detained at the FDS results in a review by the FDS to identify opportunities for systemic improvements.

10.3 Immediately eliminates the use of any QPS response, including the use of police dogs or the PSRT team, for behaviour control.

10.4 Evaluates the potential benefit of nominating an FDS staff member/s as a designated QPS liaison officer/s. The FDS staff member/s should be appropriately skilled and trained in both forensic disability and relevant QPS processes with a view to ensuring that:

  • the FDS only contacts the QPS in appropriate circumstances
  • if QPS assistance is required, it is facilitated appropriately to allow the QPS to undertake its role effectively.
Recommendation 11

That the Director:

11.1 Continues to ensure that the FDS complies with all statutory obligations imposed by the FD Act with regard to transition plans and the transition of people detained.

11.2 Ensures that transition plans developed by the FDS are effective.

That the Director-General, in consultation with the Director:

11.3 Gives consideration to legislative amendments that provide a resolution mechanism where there is no agreement to transition a person between the FDS and an authorised mental health service.

Recommendation 12

That the Director-General, in consultation with the Director:

12.1 Reviews and assesses the current legislative arrangements that apply to the person for whom the FDS is responsible, but who is not detained at the FDS, and ensure that they are receiving care and support in accordance with legislative requirements and policies and procedures issued by the Department.

That the Director:

12.2 Ensures that the full care and support arrangements in place for the person for whom the FDS is responsible, but who is not detained at the FDS, are audited by the Director.

Recommendation 13

That the Director-General, in consultation with the Director:

13.1 Reviews current arrangements with all external healthcare providers, including allied healthcare providers, with a view to ensuring that the FDS provides an appropriate level of access to health care to people detained at the FDS.

That the Director:

13.2 Reviews the current approach to providing culturally appropriate care at the FDS.

13.3 Develops a whole-of-service framework to provide trauma-informed care at the FDS.

Recommendation 14

That the Director-General, in consultation with the Director:

14.1 Reviews the structure, mix of skills and organisational culture at the FDS to align with its legislative purpose.

14.2 Reviews the complaints management policy to ensure it adequately considers the special needs of people detained at the FDS, and ensures that all FDS management and staff receive training about the application of the policy.

That the Director-General:

14.3 Establishes and maintains a conflicts of interest register at the FDS.

Recommendation 15

That the Director-General, in consultation with the Director:

15.1 Clarifies the relationship between the Department and the Director, taking into consideration statutory obligations imposed by the FD Act and legal advice.

That the Director-General:

15.2 Reviews the current classification of the position of Director having regard to the content of this report and the Ogloff report.

That the Director:

15.3 Establishes a web presence for the Office of the Director that reflects the independence of the Office, and provides public access to policies and procedures about the care, support and detention of people detained at the FDS, annual reports and any other appropriate information.

 

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