A Jersey mental health advocate is calling for a complete shake-up at the very top, following the 'very concerning' findings of an independent report into adult mental health services.
The government has published the summary and recommendations of that inspection - which exposes a lack of leadership by senior management, and a failure to learn from serious incidents.
Patricia Winchester, who is the CEO Of My Voice Jersey, says there's a very clear block to change, which has to be tackled.
"This is a wonderful opportunity for the directors at Health (and Social Services) to challenge what has been poor practice and complacency.
"If they don't do it, it will be many more years before we get the opportunity to drive through these improvements that the nurses, social workers, and occupational therapists are already delivering."
Whilst welcoming the decision to commission this report, Ms. Winchester says they've raised many of these issues for the last nine to twelve months.
"It shouldn't need a report to point out to a psychiatrist that they should engage in multi-disciplinary working, it shouldn't need a report to point out that there is an increase of multiple medications, that there needs to be more robust audit and peer challenge.
"Yet, that is what the report has had to call out.
"We need to be aware that there has been significant improvement across the nursing, occupational therapy, and social work areas, but what this report primarily is criticising is the lack of professional standards from those who are paid the most who run this service - and that is the senior clinicians.
"I think we need urgent, robust, and sustained action to challenge what has become a culture of complacency in some of our senior practitioners and outdated practice, and those who are paid for leading our services need to be accountable."
The independent review was prompted following concerns about the slow pace of improvement - and staff saying some services weren't working as well as they should be.
The Health Department's second 'Quality and Performance' report also highlighted growing pressures on adult mental health services, with more people admitted under the Mental Health Law and more staying for longer.
Ms. Winchester wrote to the Health Minister in 2019 with serious concerns about what she called 'deteriorating levels of care and treatment' at Orchard House.
When asked by Channel 103 why the independent report wasn't published in its entirety, a government spokesperson said:
"Regarding the Independent Report into Adult Mental Health Services, the summary and recommendations have been shared and not the whole report, because there are sections of the report which potentially identify individuals.
"We commit to confidentiality for all staff members who participate in independent service reviews, so everyone who participates feels able to speak, openly and honestly.
"This is integral to ensuring that colleagues participate in future reviews and means that we continue to develop a safe system within a culture of safety."