Canberra Hospital has failed to meet several areas of healthcare standards in its accreditation process, some of which have put vulnerable patients at "extreme risk".
An at times scathing interim accreditation report by the Australian Council on Healthcare Standards has identified 33 of 209 core criteria where standards were not met.
The hospital now has about 90 days to address the areas which were not met in order to keep its national accreditation.
Of the 33 areas not up to standard, two were classed as extreme risks, six as high risks, 15 moderate risks while the remaining were rated as low risks.
The report found the hospital had failed to protect mental health patients who are at an increased risk of harm, with the risk level labelled as extreme.
The results come just weeks after ACT Health announced a major restructure and parted ways with director general Nicole Feely.
Minister for Health Meegan Fitzharris said the fact the issues raised were mostly related to governance validated their decision to restructure.
She said ACT Health was taking immediate action to address the issues.
The ACHS conducted the organisation-wide review from March 19 to 23, and assessed ACT Health’s implementation of the 10 national standards.
Assessment occurred through provision of evidence, meetings with key staff and site visits
across Canberra Hospital and Health Services.
The two extreme risks related to mental health, with concerns over the five suicides in the past three years at the hospital and the failure of the hospital to take immediate action after.
"There appears to have been no regular ligature points audit undertaken nor was there any action plan done to implement strategies to prevent further cases," the report said.
"The delay in immediate actions post suicides and the delay in undertaking regular ligature audits and implementing the results of the engineers report into ligature points places the patients/consumers at extreme risk."
The most systemic problems were around the current governance system of the hospital, the report finding "some decision making priorities were not aligned to ensure patient safety".
It found while there were now good systems in place for to manage clinical services, the relationship with the governing body was unclear.
The report highlighted the many levels of approval decisions had to go through, with decision making often lengthy and convoluted when significant patient safety issues were identified.
"The current governance system with lack of clarity, role confusion and poorly defined accountable structures creates a high risk for the organisation," the report said.
It also found infection prevention was not reviewed at the highest level of governance in the organisation.
It highlighted a risk of a legionella outbreak and a failure to mitigate the risk after positive legionella samples in 2016.
The report found the hospital was not routinely completing surgical safety checklist - with completion rates at 79.8 per cent - which put patients at risk of receiving the wrong procedure, treatment or investigation.
Ms Fitzharris and Minister for Mental Health Shane Rattenbury said they were concerned by the issues raised, but confident that they would be addressed.
"Of note to me are the findings of the ACHS that there is a lack of clarity and a policy gap between corporate and clinical governance, and its recommendation to review the governance system," she said.
"These are precisely the issues that the ACT Health transition team is currently addressing as part of the ACT Health restructure that will be subject to consultation over the coming months."
ACT Health interim director general Michael De'Ath said he took immediate action after seeing the report with a group of senior staff to ensure the assessors' concerns were addressed.
"Can I can be very clear not being accredited is not an option for us."
Mr Rattenbury said the re-accreditation process would help improve the health system.
“While this feedback is disappointing, we are taking decisive action to improve coordination and integration across the mental health system, responding to many of the issues raised in the accreditation report and will rectify these issues over the coming months,” he said.
“The accreditation process is designed to help us improve as a service.
“As I have said previously, our mental health services are led by dedicated and professional staff, but we know there is work to do to improve our systems and processes so that we can ensure patients receive the right care in the right place at the right time."