Nepotism, Narcissism and Murder

“I’m from MHARS” the caseworkers from the mental health care facility would often say to get a laugh. Yes, MHARS – Mental Health Accommodation Rehabilitation Service in the little Northern Rivers town of Lismore in the state of New South Wales in Australia. Of course what others hear is “mars” – the place where some might say the “loonies” come from. My partner Michael loved using that line, though he may have said it once too often at the psychiatric ward of the hospital when he’d bring patients there. The staff at MHARS enjoyed their work, had a great spirit of camaraderie with each other and were dedicated to the care of and improving the lives of their clients.

However, all good things must come to an end, and with changes to how the organisation was run, a darker side crept in. These changes saw staff begin to leave the organisation. Michael stuck on for a couple of years, but he too had decided enough was enough and was about to leave the organisation, declaring that whilst he loved his job, the management of the organisation that had taken over MHARS had begun to introduce a degree of stress that was becoming intolerable.

The following is an account of what appears to be a need for adulation by one person in this new organisation, which eventually cost my partner, Michael his life. It is an account from multiple sources that shines the light on how the need for self-promotion by an apparent narcissistic personality, became the focus of running a Mental Health non-government organisation (NGO). It is a story where it would seem those with a mental health disability were used as a means to acquire government funding – they were a means to an end rather than an end itself.

Who is MHARS?

MHARS no longer exists, but it started as a mental health service provider in the city of Lismore located in the Northern Rivers region of New South Wales. The service was local and comprised a group of dedicated carers who had the welfare of their mental health clients at heart. They ran a refuge, a respite centre, a housing program and several other programs all targeted at those suffering a mental health crisis. It was a small organisation and with changes to state government funding policies, had to give up their autonomy to become part of another organisation in order to survive.

Who is On Track Community Programs?

“On Track Community Programs provides a range of community based support services for people experiencing mental illness, disability, homelessness or extreme disadvantage.”

This appears to be the mission statement declared on their website. Not a bad thing. No, not at all. The disadvantaged in our society do need assistance. The social workers who work at On Track Community Programs care about those less fortunate. On Track Community Programs had small beginnings in the Northern Rivers city of Tweed Heads and is run by its founder and CEO, Leone Crayden. It developed and grew as a Non-Government Organisation (NGO).

Who is Richmond Clinic?

Richmond Clinic is now the Lismore Adult Mental Health Inpatient Unit or LAMHIU though the old name has stuck. The clinic has overall responsibility for mental health patients in the area, with each mental health patient assigned a case manager from the clinic itself who is responsible for their care program. The NGOs such as On Track Community Programs are tasked by Richmond Clinic to provide the care of mental health clients in the community.

Due to changes in the criteria for funding of disability services by the federal government in Australia, smaller NGOs felt the need to merge in order to survive. On Track Community Programs saw this as an opportunity to acquire (or “take over”, as was put to me by their CEO) established NGOs and grow itself.

There was much disquiet after the merger sometime in 2007 between MHARS and On Track Community Programs. The take-over appeared to sow the seeds of a power play between the most senior manager at what was MHARS in Lismore and the CEO of On Track Community Programs based in Tweed Heads. Each doing their best to make life difficult for the other it would seem. This information filtered to me from my partner as he watched the manager of the Lismore branch begin  to crumble under the stress of playing second fiddle to a person she had a strong disliking to. On the occasions where I had the opportunity to meet separately with the Lismore Manager and the CEO, I witnessed (and was the receiving person to) their comments about each other. On one such occasion whilst at the Tweed Heads head office, the CEO proudly declared with a grin on her face as she left the room I sat in, “I can because I am the CEO” to her earlier disruption of well planned care schedules in the Lismore Branch. She had tasked Michael to work in the head office for several days to assist with the production of their annual report, knowing he was only one of two persons who had responsibility of a number of clients in Lismore. Did she know that it would upset the Lismore Manager? On another occasion, I was the receiving person to the line “I hate that bitch” but will not reveal in this instance from whom and in relation to whom. Together with information received from Michael, these little interactions gave me a glimpse of what I felt was a power play between the individuals.

Staff at the Lismore office complained of receiving little support and were constantly frustrated with having to make decisions on their own. The Lismore Manager appeared to leave much of the decision making to the staff and would often abandon the office with the alleged declaration of returning home for her “drink” – not so much said as gestured. There was the allegation by staff that the Lismore Manager was either unable to or had lost the ability to perform in her new role. They continued to feel the stress of what they believed to be mismanagement and felt their concerns were being ignored and had no one to turn to.

Since Michael’s murder, multiple allegations from both existing and past staff members have emerged relating to management’s practices that placed both trained and untrained staff in situations they were unlikely to be able to handle.

In any murder story, there is of course, the person who did it. Who is this person … David?

No attempt here is made to vilify the murderer, but rather to paint a background of why he did what he did. Now, David is a product of a difficult childhood that included various forms of abuse, neglect and addiction. He had been known to the mental health service from an early age and was relatively well managed. David was referred by LAMHIU to a government funded HASI (Housing and Support Initiative) program managed by On Track Community Programs and he was provided a unit in Lismore where he lived on his own with support from a team of mental health caseworkers.

David met Z (name not provided to protect her privacy) who herself was part of the Mental Health Refuge program at On Track Community Programs. The two individuals had entered into a relationship. In January 2009, David got an appointment with a local psychiatrist, Prof I. P. and convinced him to reduce the medications he was on as it was affecting his libido. It would appear that David got his wish as his medications were almost entirely withdrawn. In peer reviewed journal articles on medicating psychiatric patients, it is widely agreed that mood altering medication be slowly withdrawn and the patient monitored closely for adverse behavioural changes by the treating psychiatrist. This didn’t appear to be the case in this instance. The caseworkers at On Track Community Programs were not informed of the medication changes and only realised this when they were provided the scripts to collect the medications. An edited version made to the changes in medications are outlined in this report to the Health Care Complaints Commission.

The handwritten summary of critical events (given in the attachment to the right) reads in reverse chronology. Its originator is unknown but arrived together with other information sent by the CEO of On Track Community Programs. It shows David’s moods beginning to alter after the medication withdrawals in January 2009. For nearly 6 months, the On Track Community Programs Lismore branch Manager and David’s case manager from Richmond Clinic located at the Lismore Base Hospital get reports from his caseworkers (Michael and P) with concerns about David’s escalating level of aggression and violence. Yet, it does not appear that much is done to manage his escalating aggression. Were the pleas from the caseworkers ignored?

Should David have been in the community? On the Thursday before the murder, Michael and I had been driving around Lismore. We passed close to the unit where David was living and the topic of David’s release from an admission to Richmond Clinic came up. I asked the question “Should he even be in the community?” to which Michael responded, “I’ve already brought that up, but they ignored my concerns”. With Michael’s passing, I can now only guess at whom “they” referred to. It could be his immediate superior, the Lismore Manager; the Richmond Clinic Case Manager for David; or both.

What did happen that night?

That fateful Saturday night on the 27 June 2009, Michael was rostered to work at the Refuge, a 24/7 facility staffed by sole shift workers (one of several programs run by On Track Community Programs). The Refuge, located in Wyrallah Road in Lismore, was a short term accommodation facility for those with a mental health disability. Amongst the many duties of the caseworker at the Refuge was the responsibility in managing patient medication.

Z (name withheld) was a long term resident at the Refuge and was in a relationship with David. Each Saturday, David was given an option for an outdoor recreational activity. That Saturday, David’s caseworker had brought him and his girlfriend to Tallow’s Beach near Byron Bay. At the end of the outing, Z was returned to David’s unit as she had been co-habiting there for some days. According to the caseworker, David had felt agitated that day and through his delusions, shared with the caseworker his concerns about losing Z to other men at the Refuge. However, these agitations were not made known to anyone.

That night over at the Refuge, Michael had noticed Z’s absence and whilst difficult to prove, was likely concerned about her need to be medicated, a task he was responsible for. The unit that David occupied was but a 2 minute drive away from the Refuge and Michael brought the medication across with the intention of asking Z if she would like to return to the Refuge that night. Z said “yes”. She had also indicated that she was meant to return to the Refuge that morning. These events were surmised from statements made to the investigating Lismore detective by both David and Z.

David, being a paranoid schizophrenic and highly jealous of other men, was constantly under the delusion that others wanted Z for sex. It did not matter that Michael was gay and was at the unit to simply offer Z any assistance she might have required. An ensuing altercation broke out.

The panic that ensued in the organisation after Michael’s murder manifested in the CEO attempting to placate me in what I considered the most insensitive manner.

The very first day of my loss and in inconsolable grief, I received a call from the CEO that started something like this : “In incidents such as these, our company policy is to …”. I never heard the rest of that sentence as the phone left my hand in a flying skid across the floor. What an absolutely insensitive and matter of fact way to speak in this instance by a person leading an organisation purporting compassion for those with a mental health disability. I am to this day, astonished at the lack of empathy shown by this person toward myself who was freshly grieving the loss of a loved one. These attempts to contact me did not stop there but continued. I tried but could not find the genuine compassion in her requests to meet with me. They felt false. They had all the signs of a person needing to “go through the motions” to protect the name of the organisation because these actions are what WorkCover and the courts will look at. To this date, no apology has ever been offered for the loss that Michael’s family have endured.

I did eventually give into her persistence and agreed to meet with her. She shouldn’t have pushed so hard. I had a companion with me during that meeting, and we detected what we felt were evasive answers to a number of questions we had. This meeting did nothing to quell my suspicions about the motives under the guise of “assistance”, but everything to rile me into a resolve that I would expose the truth about what I had been consistently told about the organisation’s CEO and leader. It gave me the energy to ensure that the organisation would be exposed for their failure to provide a safe work environment. By pushing too hard in such a disingenuous manner, the CEO had shot herself in the foot.

The police were quick to interview the murderer and a witness (Z, his girlfriend) present at the scene on the night in question. They determined the reason for Michael’s presence at the unit, which fitted in perfectly with his job description. He was responsible for Z who was a patient at the Refuge where he was working his shift that night. He brought her medication but at the same time, asked if she wanted to return to the refuge. This information was very quickly disseminated within the On Track Community Programs workplace and to myself.

Plain simple facts – he was doing his job. Should he have chosen not to bring the medication to Z or look in on her welfare, there was the likelihood he would have been disciplined for failing to carry out his duty by ensuring the well-being of Z and ensuring she received her medication.

However, the knowledge made available by the police to On Track Community Programs was absent in the statements to WorkCover by both the Lismore Manager and the CEO regarding Michael’s visit to the unit. A murder occurring at a workplace would look extraordinarily bad for the organisation, especially if the victim was simply doing his job. There was a definite potential it would reflect negligence in adherence to the Occupational Health and Safety Act.

But whatever the reasons for the failure on the part of the Lismore Manager and the CEO to provide WorkCover with information gathered by the police is open to speculation. The persistent line from the management to staff members was simply that he should not have gone to the unit. It was a line that had managed to find its way into the community as well and it is suspected that this was actively carried out. In a written statement provided and signed by the CEO of On Track Community Programs to WorkCover, the following points were made:

• He apparently hadn’t used the company car. From this, one can only conclude that the registration details of the vehicle would have saved him even though during the time of the murder, Michael was not in the car but at the unit of the perpetrator. Perhaps I may be ignorant about the capabilities of the On Track Community Programs registered Toyota Corolla, but there could be the chance that the car was kitted out by the makers of 007 Bond vehicles?
• He went after hours. Well of course, we all know that Mental Health patients are more violent after 5pm and really, no one should be in contact with them after this time.
• He apparently hadn’t written down his movements on a white board locked away in the staff room. Of course if he did and was in trouble, that information would have been telepathically received by anyone at the Refuge (or elsewhere in the city for that matter) and they would have been able to speed to the location to enact a heroic rescue. Maybe Superman, Batman, Wonder Woman or all three might have been in town that night.

So, the above is what a CEO of an organisation comes up with, then makes a signed declaration that she had no idea why he was there. Perhaps she genuinely did not know. It can however be granted that the circumstances are difficult to prove beyond reasonable doubt in a court of law. Unfortunately, as both David and the witness were both mental health patients, their testimony in spite of the matching information, are not admissible. This does provide a loophole for On Track Community Programs to declare that the reasons for Michael’s presence at the unit were unknown.

The branch manager in Lismore decided she would take the path of stating that he was involved in “cross program interaction”, which was apparently a big “no no”, in her claim to WorkCover. Except that the Lismore Manager had forgotten that cross program interaction was in fact an encouraged activity that occurred on a highly regular basis. She had also forgotten that she had herself caused stress to Michael by tasking him to simultaneously work his job and that of an absent colleague from a different program only weeks earlier. The CEO herself submitted a report that indicated cross-program interaction occurred on the day of the murder by another colleague. More can be read about the Lismore Manager’s declarations of documented (but not written) policy regarding so called cross-program interactions here.

It has since been noted by the Industrial Court that evidenced from numerous On Track case notes, the work regularly performed by the employees often involved an intermingling of both clients and work between the HASI program and The Refuge and Michael did not have any strictly defined roles working exclusively as a HASI worker or a Refuge worker.

Was there an attempt to shift the blame? It is understandable that any organisation would want to protect its name. However, the concerted effort at placing blame on the victim for his own death doesn’t do much for an organisation set up to be sympathetic towards others. Perhaps the following information may shed some light on what is more important to the organisation.

At a meeting with the CEO to discuss the development of their web site that I was hired to assist with, I witnessed her need to promote the organisation to other similar establishments rather than to those genuinely in need of the services. I had questioned the industry specific language used in the website content and asked whom the target audience was as I didn’t think that the terms used would be easily understood by those seeking mental health assistance. I was absolutely dumbfounded when I was told that it was to broadcast (read … “blow our trumpet”) the success of On Track Community Programs to other organisations in the industry. The mental health client audience was secondary and this was signalled with the gesture of an open hand facing and pushing away.

On a separate occasion, whilst sitting in with the management team, a member declared in a conversation with me : “Thank God I don’t work with those people”. An upturned nose made on the word “those” and in reference to the mental health clients of the organisation. I was shocked to here this remark as I was a virtual outsider to the organisation and the comment was openly made to me. I am unsure if my gaping jaw was obvious. I related this incident to a colleague of Michael’s and she related a similar incident but involving the CEO whilst standing together and in conversation at the main Lismore office. A dishevelled man walked past on the footpath outside the building and the CEO with pursed lips and a look of disgust asked “Who is that?”. To which the staff member replied “He’s one of our clients”. It was not the question so much as the contempt in the CEO’s voice that shocked the staff member.

The organisation was set up to show compassion to and help the less fortunate. However, the actions (or reactions) of the senior management toward the mental health clients appear to belie this. It would hence not be a stretch of the imagination to see that if compassion for those in need appear to be absent, then attempting to shift the blame for Michael’s murder onto himself can only be what I’d assume to be normal behaviour of some within the organisation. I hope I am wrong, but what does one make of the knowledge gathered?

A root cause analysis was carried out by the hospital (Richmond Clinic) after the event. It reveals some startling facts about the care and handling of information regarding the mental health patient.

Before reading ahead, place one hand under your chin to counter the potential for jaw drop.

1.   “An underestimation and lack of systematic assessment and documentation of risk in a man with a significant past history of repeated violence led to an inappropriately coordinated and non assertive community care plan which did little to address the situation or recurrent relapse and associated violent behaviour.”

2.   “Limited inpatient discharge planning did not include all agencies contributed to an inappropriate risk (of violence) assessment and non assertive community mental health care plan which may have contributed to the likelihood of the client’s symptoms escalating and going unnoticed.”

[In the report “Tracking Tragedy 2008 – Fourth Report of the NSW Mental Health Sentinel Events Review Committee”, it was highlighted that communication issues are consistently a major factor in studies of preventable medical error. It would appear that the warnings of the Mental Health Review committee went unnoticed.]

3.   “Poor communication between Health and HASI [a Housing program run by On Track Community Programs] staff in the care of a man with a predictable risk of violence may have contributed to a lack of interventions for ensuring strategies for detecting and responding to increased violence were in place.”

As indicated in the report on each of the above points, communication was lacking in all areas, as was knowledge, skills and competence.

However, unlike the organisation that Michael worked for, the hospital through its Root Cause Analysis had shown it was ready to investigate and take responsibility for the failures and to put into action recommendations for an improvement in health delivery standards. Would it have been too much for On Track Community Programs to be as clear and transparent as Richmond Clinic had been?

In the 2008 Tracking Tragedy report, the summary paragraph on homicide likelihood by a mental health patient reads as follows:

“Those who cause serious, potentially fatal violence are likely to be unemployed, have a chronic schizophrenic illness, be substance abusers and have a history of violent behaviour. Those with severe mood disorder are another significant group. In the case of people with a psychotic condition, delusional belief that they are under threat is a common phenomenon.

A history of violence was a common characteristic (64%) of those suffering from a mental illness who committed homicide or caused serious injury.”

The above paragraphs accurately describe the perpetrator of Michael’s murder. It would appear that the clinic and the On Track Lismore manager had failed to read this report and be proactive in preventing a homicide. Then again, the report also states that Communication is an issue.

It was well known that Richmond Clinic’s clinical Case Manager for the mental health patient David, suffered what was facetiously described by the On Track Community Programs caseworkers as a “work phobia”. The Case Manager was close to retirement and chose to carry out as little of his responsibilities as he could, leaving much of his work to both Michael and his colleagues, untrained as they were in those tasks pushed onto them. Richmond Clinic, in its assessment of the failures, acknowledges that the bulk of the failures lie with this one individual. However, the Case Manager passed away less than a year after Michael’s murder and much of the responsibility of the clinic for his failures died with him.

Both Michael and his colleagues felt abandoned by the “system”. Richmond Clinic failed in its management of the patient and in identifying situations that were likely to lead to safety concerns. The management at On Track Community Programs at the same time, didn’t seem to be overly concerned about the lack of safety they placed their staff in. Risk Assessments were never obtained to determine if David was suited for the HASI program and to be out in the community. Days before Michael’s murder, it appears that a letter was sent by staff to the management addressing continued safety concerns at one of the organisation’s facilities. These concerns were dismissed in a written response to the staff.

Whilst the Health Care Complaints Commission (HCCC) looked into the handling of the situation by Richmond Clinic, disciplinary action was not taken as the clinic had identified their mistakes and made recommendations for improvement. WorkCover NSW were unable to look into Occupational Health and Safety concerns of the Clinic because Michael was not employed by them, it was however heartening to note that changes would be made by the Clinic to a number of practices to minimise future risks.

However, there was wide discontent felt by Michael’s family as well as many current staff of On Track Community Programs in the initial WorkCover investigation to bring On Track Community Programs’ culpability to light. A team of family members led by myself identified areas of concern and prepared an assessment and provided sufficient background information for an immediate re-opening of the case. A thorough investigation was carried out, which uncovered failure by On Track Community Programs to provide a safe work environment. To the delight of the family and many in the mental health sector, in July 2011, WorkCover commenced prosecutions against On Track Community Programs Ltd pursuant to section 8(1) of the Occupational Health & Safety Act.

From conversations and emails received from both past and present staff regarding On Track Community Programs and its management team, an insight into the darker side of the organisation can be gained. Whilst these can only be taken as allegations, the reader should note that they are not lightly made by the contributors. These allegations (excerpts from email communications received) are listed here to paint a picture on the level of safety concerns for staff and the attitude of the CEO toward shielding its lax practices.

Anyone can be a mental health carer :  “I was amazed when I heard one of [the CEO’s] mates, John Smith (name changed), was employed as Disability Support Worker in the same premises of a dangerous person with disability. John Smith admitted that he was a tourist company operator and didn’t know a thing about disability care but he was going to give it a go.”

The use of reception staff in mental health care roles : “… reception staff who had suffered mental anxiety themselves (when) transferred to do personal care with high needs clients – when I expressed my concern re: this to the CEO I was told that it would be alright. The staff member involved had a very negative reaction to the unreasonable pressure of being transferred out of reception to a difficult client and could not continue these duties.  Another receptionist was transferred to be a disability support worker and twice confused the clients with the result that the wrong medication was administered to the client. These clients were profoundly disabled in wheelchairs and deserved much higher quality care.”

It’s a matter of opinion : “One of [the CEO’s] favourite line when put on the spot is that we just have different perceptions. She has no problem lying and has admitted this to me in the past when I could not as a matter of conscience be dishonest in business dealings.”

Where did the money go? : “On Track Community Programs has experienced significant growth in recent years and the funding bodies such as North Coast Area Health Service, DADHIC, Dept of Health and Ageing, FACSIA, DOCS have no idea at how the funds are allocated in a way that favours the select few and not the majority.”

Silence is golden : “Others have been made redundant and many have then received a monetary golden handshake in exchange for signing a Deed of Release agreeing not to ever talk about On Track Community Programs in future.”

Quick, let’s make changes now : “I was amazed to find that the external door locks could be opened easily without a key – both the CEO and 2IC knew about this for years and only took the measure of enhanced security following Michael’s death.”

This is but a tiny list. WorkCover NSW has now received separate reports of bullying by On Track Community Programs. The allegations made by multiple staff against the CEO would point to a person with a severe narcissistic personality. Wikipedia provides a description of the Narcissistic personality disorder (NPD) or Psychopath as

“a personality disorder^[1] in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity. This condition affects one percent of the population. ^[2][3] First formulated in 1968, it was historically called megalomania, and is severe egocentrism.”

Words used by various individuals from the mental health community to describe the CEO include “megalomaniac”; “kingdom builder”; “power hungry” and “snake in the grass”. It is no wonder that many staff suffer the distress that they do and many have left the organisation in disgust. Others have left from having had their positions “restructured”.

After the constant mantra of “It was his fault, he shouldn’t have gone there” by On Track Community Programs, WorkCover NSW after a thorough investigation had found the organisation to be guilty of failing to ensure a safe work environment for their staff under the Occupational Health and Safety Act 2000. Two years to the day of Michael’s passing, WorkCover served On Track Community Programs a summons to appear in the Industrial Court of NSW.  It would be another 20 months after that date before they would finally come forward and admit their guilt. At each scheduled court Directions Hearing, the organisation sought adjournments and gave no indication if they would plead either guilty or not-guilty to the charges brought against them. As On Track Community Programs failed to plead either way and continued seeking adjournments, the court deemed their fourth request for an adjournment to be a plea of not-guilty and proceeded to set a date for the Defence Hearing in court which would have required the organisation to defend the claim of not-guilty.

A week from the date of the Defence Hearing set by the court and knowing they had stretched the court’s patience, On Track Community Programs came forward and pleaded guilty to an amended (lesser) charge and attempted to trivialise the gravity of the charge by their application for a Section 10 of the Crimes (Sentencing Procedure) Act 1999. That is, to have no conviction recorded against the name of the organisation and to have no monetary penalty imposed. A Section 10 is often sought by defendants of trivial crimes, for example, speeding fines.

At the final Defence Hearing in early June 2013, the defence lawyer argued for over two hours to lay blame squarely at the feet of the North Coast Area Health Service (NCAHS) as well as the Community Mental Health service. However, the contradiction in this is that he also claimed that all three organisations (the third being On Track Community Programs) had a share in the care of the mental health patient – sadly, that share did not appear to extend to any responsibility by On Track Community Programs for the events in question. The defence lawyer repeatedly emphasised that the North Coast Area Health Service was totally to blame for releasing the perpetrator from their facility rather than acknowledge that On Track Community Programs itself had a duty of care to request a Risk Assessment and protect their staff from a client that had the potential to be violent.

The defence lawyer continued to push blame onto the victim as well, indicating that there was no reason for Michael’s presence at the unit of the mental health patient. Yet at the same time, he acknowledged that Michael had been rostered to work at the Refuge that night and had responsibility for the clients of the refuge, which included the girlfriend who was at the unit of the murderer. The defence lawyer had failed to indicate that the possibility for Michael’s presence at the unit may have had something to do with the fact that he had a duty of care towards the client of the Refuge and might have been concerned for her welfare.

In an attempt to reduce or avoid paying any penalty altogether, On Track Community Programs when initially requested, failed to provide full and proper records of their financial statements even though they were available, but instead “suggested that they were expected to suffer a loss in the upcoming tax year.” However, the judge noted that “in reality, based upon records produced by the defendant (upon cross-examination), there could not be (and was not) any issue of financial incapacity to pay or lack of financial means”. On Track in its 2012 Annual Report proudly claim an increasing grant revenue and an asset value of 3.732 million Australian dollars.

On 27 September 2013, Justice Michael John Walton of the Industrial Court of NSW handed down his judgement. The decision summary states:

On Track Community Programs was convicted around the charge of having failed to obtain any proper Risk Assessment on the client that was release from the mental health clinic. They had also failed in obtaining the discharge summary of the patient that was available to them when he was released from the Clinic just three (3) days prior to his committing the murder. The discharge summary noted that there was a moderate to high risk of violence when David was manic or psychotic.

The above failures meant that staff were not armed with the proper information about the mental health, psychotic states and violent behaviour of the patient. The judge highlighted the gravity of the offence and based his conviction and fine on the organisation’s failure to prohibit staff from interacting with the client until the “all clear” was given. Whilst it is accepted that there are limits to eliminating the risk of violence when working with the mentally ill, it was possible to assess risk factors and to manage them by a more comprehensive and formal risk assessment and risk management plan. On Track’s home visiting policies also did not require staff to be accompanied. It is an obligation of On Track under the OH&S Act to control and minimise exposure to risks.

The full judgement can be found here.

In the immediate period following the murder, On Track responded by making changes to their home visiting policies. The judge indicated that these steps taken revealed in clear terms the simple and decisive remedial steps which may have been taken by On Track to abate the risk prior to the incident. In addition, granting that On Track did have some policies in place, they were considered inadequate. Any relevant policies to deal with ‘aggressive’ or ‘violent’ patients that On Track Community Programs did have, did not apply to employees of their “Refuge” program where Michael was working that night.

The court has fined On Track Community Programs $115,000. The amount whilst considered average is significant as community organisations are often viewed as being unable to afford the fines imposed and it would deplete funds from the services they deliver. However, the court considered On Track had sufficient funds to pay the fine and also considered the gravity of the offence. The court also indicated “it is necessary to ensure that the penalty properly reflects the need for general deterrence so as to draw attention … in particular [to] those dealing with mentally ill and vulnerable members of society”.

The penalty imposed by the court is in addition to the costs payable by On Track Community Programs to the prosecutor (indicated by WorkCover to be approximately $70,000) as well as their own significant legal costs (10s of thousands of dollars at least) that was mounted to defend the prosecution.

The name of On Track Community Programs is now tarnished in the mental health industry. Few have positive words for their management although the dedication of staff are highly praised. When Michael was alive, he constantly provided information regarding the failures of the management to lead. He relayed how he feared for his life due to the lack of safety procedures in place. At that time, I made a promise to him that when he left the organisation, I would publicise his concerns. Today, the distaste for the organisation is so acute in the mental health sector that rumours abound regarding attempts to divert funding to the organisation or to have the organisation abolished altogether.

After Michael was murdered and till today, no family member has received an apology from the management of On Track Community Programs for our loss. It is not helped that the CEO labelled me as “the enemy” for seeking justice to clear Michael’s name of the rumours that were viciously spread. Michael’s immediate work colleagues on the other hand were more than supportive. The eye opener regarding all that was wrong with the organisation came in the multiple emails and calls from both current and past staff with allegations of bullying, unsafe practices, funding mismanagement, nepotism and a host of other misdeeds. What I had been made aware of by Michael was but the tip of the ice-berg and simply had no idea of the true state of the organisation. Many of the allegations come from persons that have worked closely with the CEO and have a first-hand experience of how the organisation is run. The related stories and reading were simply jaw dropping. Many staff had the genuine fear that they too would be victims of those whom they cared for and as evidence suggests, attacks and murders continue to occur in the mental health sector to this day.

The successful prosecution of On Track Community Programs by WorkCover NSW is not only welcome news to myself and other family members but also and in particular his work colleagues, those in the mental health industry and by members in the greater community who knew and respected Michael as an individual.

It is hoped that government funding bodies take note of the judgement handed down by the Industrial Court against On Track Community Programs and ensure that highly sought after but limited funds are distributed in a manner that maximises the benefits to those most vulnerable in our society and not the select few that posses an unnatural desire for adulation. It is also hoped that the judgement will be adopted by managers in the mental health industry to provide a safer work environment to those individuals who dedicate their lives to improving the lives of those who are less fortunate. In that light, it is hoped that Michael’s passing will not be in vain.