Complaints – A vital window into consumer experiences of restrictive practices

Ms Jennifer  Black1, Mr Keir Saltmarsh1
1Mental Health Complaints Commissioner, Melbourne, Australia

This presentation will discuss the work to date of the Victorian Mental Health Complaints Commissioner and outline the key themes identified from consumer complaints about public mental health services. In particular it will explore the themes seen in complaints about restrictive interventions, approaches to responding to these complaints, and highlight some of the service improvements made as outcomes of complaints. The presentation will provide case examples as well as detailed aggregated data on numbers and types of complaints which would be useful for service leaders in thinking about their approach to restrictive interventions and ways in which the associated harms of such practices can be addressed. It will highlight the importance of complaints and collaborative reviews of incidents, for hearing and responding to consumer’s experiences of restrictive practices. It will explore how this information can provide valuable insights about the culture of the service and the actions required to reduce or eliminate the use of restraint or seclusion. It will unpack how service leaders can work with people’s experiences in a more meaningful way to influence change within their own organisation, as well as highlight some of the barriers and pitfalls to effective use of lived experience stories in this context. In addition the presentation will include some personal reflections of the Deputy Commissioner who has moved from a position of a Clinical Service Director into this statutory oversight role.


Jennifer Black has a long career history leading clinical mental health services both in Australia and the UK . She is currently the Deputy Commissioner for the Mental Health Complaints Commissioner in Victoria, and through the resolution of complaints and the safeguarding function of the office, she works with services to foster service improvement and with government to influence systemic change.

Keir Saltmarsh has worked for the Mental Health Review Board (2008-2013), the Victorian Institute of Forensic Mental Health (2004-2008) and in the Mental Health Branch at the Victorian Department of Health and Human Services (2008-2014). He is currently working as a Senior Education and Engagement Officer at the Mental Health Complaints Commissioner.


TERP focuses on identifying, avoiding and reducing harm across all environments in which the care of people with mental ill health is provided. TERP inforces Australia’s commitment to reduce the use of, and eliminate restrictive practices as a priority for action. Each jurisdiction, in conjunction with the Safety and Quality Partnership Standing Committee and the Commonwealth Government, works towards this vision by holding a series of forums providing an opportunity to learn and grow from local and national initiatives to eliminate restrictive practices and create a dialogue for future care.

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