The Independent Commissioner Against Corruption South Australia released its report, Oakden: A shameful chapter in South Australia’s history, last week. The report’s author, Bruce Lander QC, called the Oakden revelations a “shocking indictment on its management and oversight”.

Continuing, he warned that closing the facility without fully engaging with the reasons for its failures leaves open the risk that similar failures in other facilities could proliferate.

Speaking in Canberra on Thursday, however, the Aged Care Reform Taskforce’s Catherine Rule said better communication could have helped prevent the years of abuse and neglect.

“Absolutely, there were some deficits in the system of information sharing – at both a Commonwealth level and between the Commonwealth and the states,” she told the standing committee on health, aged care and sport.

According to the ICAC report, one 70-year-old patient, Graham Rollbusch, died after head and neck injuries sustained in an attack by another resident in 2008. A year later, the murder case was dropped with media reporting the accuser had died. However, there was no coronial inquest.

In 2014, a staff member registered concerns about excessive use of restraints, and in 2016 another resident, Robert Spriggs, was referred to the Royal Adelaide Hospital with significant, and unexplained, bruising.

That same year, a nurse attempted a catheterisation procedure without the patient’s consent. The incident went unreported to the Australian Health Practitioner Regulation Agency.

Later that year, a patient died after choking on a piece of food while being left attended. There were other instances of overmedication and Mr Spriggs’ case grew in prominence until the federal government announced an audit of the home on 6 March 2017.

Mr Lander expressed shock that the relevant ministers knew so little about the issues at the home.

While Labor MP Steve Georganas questioned whether more effective auditing could have prevented the Oakden failures, Ms Rule said it would be “very hard to speculate whether that would be the case”.

She said the Carnell-Paterson review into the national aged care quality regulatory processes found there were a number of gaps in the regulatory system.  

The department of health’s aged care quality and regulatory reform branch’s assistant secretary Amy Laffan noted that there was a problem with the accreditation schedule, as facilities knew of them in advance and as such could prepare for the assessment. The government is now moving to unannounced reaccreditation audits.

Mr Lander’s report argued that there are a number of “salient lessons about identifying and properly dealing with complaints”, and said appropriate staffing and understanding of staff responsibility comes into this.

He said, “[The report] highlights what can occur when staff do not step up and take action in the face of serious issues. I appreciate that it is not always easy to step up in such circumstances.

“But that is what is expected of every person engaged in public administration and particularly so in respect of public officers in positions of authority who have information that might expose serious or systemic issues of corruption, misconduct or maladministration.”

Going forward, Ms Rule said it’s critical that the “right kind of people” work in the sector, and that the sector attracts those people with appropriate pay.