The Ombudsman has published a final investigation report of the Southern Adelaide Local Health Network (SALHN), concerning a decision to place a level 1 inpatient treatment order (ITO) under the Mental Health Act 2009 on a young person who presented at Flinders Medical Centre.
The Ombudsman’s report was tabled in both houses of the Parliament of South Australia on 5 May 2026.
The Ombudsman’s investigation concluded that the SALHN made several errors in relation to the placement of the ITO including the following:
- the SALHN failed to reasonably satisfy itself that the criteria for placing the ITO under section 21 of the Mental Health Act had been met
- the SALHN failed to comply with the provision of information requirements under section 23 of the Mental Health Act
- the SALHN failed to adequately document the reasons for the placement of the ITO.
The Ombudsman has made five recommendations as a result of her investigation, which includes that the SALHN apologises to the young person and their family, that it provides a letter to be read alongside their medical records noting the ITO was placed in error, and also that there be policy and process change. The SALHN has agreed to implement these recommendations.
The Ombudsman also made a recommendation for the South Australian Government to consider amending the Mental Health Act to enable individuals to seek a declaration of invalidity in relation to an ITO.
South Australia’s mental health legislation is currently undergoing a review, which is an opportunity for this recommendation to be realised, and the Office of the Chief Psychiatrist has indicated its willingness to consider this recommendation as part of the review.
