The Canberra Hospital's Adult Mental Health Unit was persistently over its funded capacity in the past year, according to complaints made to an independent monitor of people in custody or care in the ACT.
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The Official Visitor for Mental Health received 86 complaints in the year to June, a report tabled in the ACT Legislative Assembly showed.
They spoke with 200 staff and 147 patients of mental health units across Canberra, including the Adult Mental Health Unit, the Mental Health Short Stay Unit, the Brian Hennessy Rehabilitation Centre, Dhulwa Mental Health Unit, Calvary Hospital Ward 2N, the Older Person Mental Unit Inpatient Unit and Hyson Green.
One of the Official Visitor's chief concerns was the capacity at the Adult Mental Health Unit.
The unit has 40 beds but is only funded for 37.
An ACT Health spokesman said since last September, the occupancy had ranged from 35 to 40 beds occupied.
"The three unfunded beds can be utilised if needed. When required, leave beds are utilised over the weekend to accommodate individual clients," he said.
ACT Mental Health Consumer Network executive officer Dalane Drexler said they had told the government there were not enough beds to meet demand when the unit was being designed.
"Like the NDIS, I think they were surprised with how much need was out there," Ms Drexler said.
She said the high numbers of patients left staff "no time" to fully support them.
"During one most recent visit the behaviour of one of the patients in the unit put staff at risk and it put the person at risk. I think having so many people in the unit all the time is making it difficult for staff," Ms Drexler said.
She said many people were being checked out earlier than they should be, in some cases "to nothing".
Ms Drexler said there were few "step-up, step-down" facilities in Canberra, where patients in the early stage of a crisis could seek urgent help and where those leaving a mental health unit could transition out of acute care.
She believed the University of Canberra's new sub-acute public hospital could help, but right now people were being turned away because they were "too well".
The ACT Health spokesman said when there was limited bed availability and patients coming in from the Emergency Department, the treating team looked at whose discharge date could be brought forward "safely".
Staff took the patients' support network into account when deciding if to release them early and the Crisis Assessment and Treating Team (CATT) followed up with them.
"Suitable patients are also considered for available beds at the Brian Hennessey Rehabilitation Centre or the Withdrawal Unit," he said.
The report also raised concerns about a patient on Calvary Hospital's Ward 2N not seeing a doctor for two days between April and June.
"That would have been an extremely rare occurrence and would only arise in the event of an unplanned medical staff absence with backfill not available," the report said.
"All patients are reviewed by a doctor on admission and reviewed within 24 hours of admission."
However ACT Health was unable to say how many other mental health patients were not seen within 24 hours because the data was not "routinely collected".
A spokesman said admission to Ward 2N was via the Emergency Department, which meant the patient had to be medically reviewed, or via the Community Mental Health Team.
He said there were procedures in place for urgent medical reviews "as required".