Chief Psychiatrist’s Review Report: Building rehabilitation and recovery services for people with severe enduring mental illness and complex needs – including those with challenging behaviour


In response to mounting concern from clinicians and families about the quality of current services, the Chief Psychiatrist instigated a formal review into the treatment and care of people with a serious, enduring mental illness and complex needs.

The Review found that although WA has some of the components of a rehabilitation and recovery service system, there are some very significant gaps, services are fragmented and there is limited access to specialist rehabilitation treatment and care.

Ten recommendations have been made to develop a comprehensive, integrated rehabilitation service system to effectively meet the needs of these individuals and their families.

Chief Psychiatrist’s Audiovisual Communication Guidelines for Mental Health Infection Control Directions (No.2)

The Chief Psychiatrist has issued this guideline for the use of audiovisual communication in response to the requirement of the Mental Health Infection Control Directions. These Directions were  issued under the Public Health Act 2016.

The Direction enables Audio Visual Communication to be used when conducting MHA 2014 section 48 examinations & MHA section 79 examination assessment criteria in the  prescribed specified situations.

It is essential that all medical practitioners and AMHPs read the attached Audio-Visual Communication guideline and the Mental Health Infection Control Directions (No.2) which were effective from 2 September 2020.

Should you have any queries, please discuss with your service Clinical Lead in the first instance.

Chief Psychiatrist’s Guideline: Audiovisual Communication (December 2020)

Mental Health Infection Control Directions (No. 2) (September 2020)

Chief Psychiatrist’s Review into the Treatment of Ms Kate Savage by Child and Adolescent Mental Health Services

The Chief Psychiatrist was requested by the Minister for Mental Health to undertake a Review into the tragic death of Ms Kate Savage, age 13 years.  The scope of this Review also considered any gaps in mental health service provision for this cohort of children.

Kate’s death cannot be rationalised.  This was and is an unimaginable loss for Kate’s family.

The Review identified a huge surge in demand for Child and Adolescent Mental Health Services (CAMHS) in recent years.  CAMHS development has not kept pace, and this has placed significant pressure on clinical staff and the WA community. It is critical to provide mental health treatment services for young children, as well as for older adolescents – if we do not provide this early life care, we will condemn a generation to worsening mental health throughout their lives.

Seven recommendations have been made, which will facilitate improved care in the short term, and also, importantly, create steps to rebuild CAMHS.  

Report: Chief Psychiatrist’s Review into the Treatment of Ms Kate Savage by Child and Adolescent Mental Health Services

Guidelines to improve sexual safety in mental health services launched at Fiona Stanley Hospital, Mental Health Unit

  • The Chief Psychiatrist is responsible for setting and overseeing the standards of care provided by mental health services to consumers in WA.
  • Ensuring people accessing mental health services feel and are sexually safe is essential to their recovery.
  • The Chief Psychiatrist has developed Guidelines for the Sexual Safety of Consumers of Mental Health Services in Western Australia, which provide guidance and practical strategies to improve sexual safety in mental health services.
  • The guidelines were launched by the Honourable Alanna Clohesy MLC, Parliamentary Secretary for Mental Health
  • The launch was well-attended by clinical service leads, health and mental health agencies and community sector representatives, and consumer and carer representatives.

Sexual safety refers to being and feeling psychologically and physically safe, including being free of, and feeling safe from behaviour of a sexual nature that is unwanted, or makes another person feel uncomfortable, afraid or unsafe.

The Guidelines are aimed at ensuring that all people- consumers, their families, visitors and staff- are sexually safe in WA mental health services. The guidelines are part of a commitment to providing person-centred, recovery-focused and trauma-informed care, through developing best practice guidelines for mental health services. They were developed through wide consultation with consumers, carers, community members and clinicians.

While they apply to mental health services under the Chief Psychiatrist’s remit, all services in WA who provide therapy or support for individuals with mental illness are strongly encouraged to use the Guidelines to improve sexual safety within their agency.  

The Guidelines are available on the Chief Psychiatrist’s website – Chief Psychiatrist’s Sexual Safety Guidelines. Copies are available by emailing  (please note mental health services under the remit of the Chief Psychiatrist will receive copies in the mail)

Chief Psychiatrist congratulates Professor Helen Milroy – 2021 WA Australian of the Year

Dr Nathan Gibson – Chief Psychiatrist congratulates Professor Helen Milroy on her recognition as the 2021 WA Australian of the Year.

Professor Milroy is a highly respected expert in the field of Child and Adolescent Psychiatry, and has made significant contributions to the fields of research, education and training in Aboriginal and child mental health with a particular focus on grief and trauma. Her contribution to the Royal Commission into Institutional Responses to Child Sexual Abuse has been invaluable in furthering the commitment to trauma informed care. Her recognition as WA’s 2021 Australian of the Year is welcome news for the field of mental health in Western Australia.

Professor Milroy was also recently awarded the 2020 Australian Mental Health Prize

WA Seclusion and Restraint Data: 2019-2020

The Chief Psychiatrist is committed to reducing the rate of restrictive practices, seclusion and restraint, in Western Australia (WA).  In order to promote transparency in the use of restrictive practices in WA, the Chief Psychiatrist has committed to publishing the rates of seclusion and restraint bi-annually for each authorised mental health service. 

The rates of seclusion and restraint for the 2019 – 2020 financial year (1 July 2019 – 30 June 2020) is now available.

WA Seclusion and Restraint Data 2019 – 2020: Quarters 1-2, 3-4, and Financial Year

(note – figures updated 03/11/2020)

Chief Psychiatrist’s Annual Report 2019-2020

The Chief Psychiatrist’s Annual Report 2019-20 has been tabled in WA Parliament.

‘Ensuring Safe and High Quality Mental Health Care’
Annual Report of the Chief Psychiatrist of Western Australia
01 July 2019 – 30 June 2020

It highlights the dedicated work of the staff of the Office of the Chief Psychiatrist, and very clearly demonstrates the value of the role of the Chief Psychiatrist to the Western Australian community.

The report contains critically important messages for services and system planners.

If you would like to provide feedback about the Chief Psychiatrist’s Annual Report 2020, please follow this link – Chief Psychiatrist’s Annual Report 2020 Feedback

The Chief Psychiatrist’s message for Mental Health Week

During Mental Health Week 2020, it is important we take time to think about, and respect, inherent dignity and humanity when considering severe and enduring mental illness: the humanity of those individuals who are living with severe mental illness, the humanity of those in the community who give so much to support individuals with mental illness, and the humanity of those clinicians and staff who devote their lives to reducing suffering.

Updated Guideline: Management of acute behavioural disturbance in COVID-19

The Department of Health has released version two of the Guideline: Management of acute behavioural disturbance in COVID-19.

The guideline now includes the latest policy advice on the use of airborne precautions (Section 6.1 of the Guideline), for patients who are confirmed, probable or suspected cases of COVID-19, and on the use of PPE (including fit-checking) in a mental health setting.

Guideline: Management of acute behavioural disturbance in COVID-19 (version 2 published 31/08/2020)

Further details can be found on the Chief Psychiatrist’s Activities and COVID-19 Response page.

Chief Psychiatrist’s Targeted Review Report: Homicides allegedly committed by people who have had contact with, or who were being treated by, WA Mental Health Services during 2018

Homicides by individuals with serious mental illness are rare. In 2018, Western Australia experienced a spike of nine homicides allegedly associated with individuals who were patients of, or had recent contact with public sector mental health services. The Chief Psychiatrist undertook a Review to consider this issue.  This Review found a mental health system under significant pressure, and identified similar associated factors to those that lead to a range of poor outcomes in mental health.  It was noted that these factors had been identified by several historical reviews.  Three recommendations have been made, aimed at system improvement.