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.