Mental health watchdog secretly puts a line through vital investigations

Victoria’s mental health watchdog stopped investigating systemic issues including the availability of beds for young patients and the illegal use of restraints after successive state government cuts to its powers, budget and staff.

Outraged mental health groups have warned of major safety issues for vulnerable Victorians and are demanding the state government explain who is now overseeing the mental health system, after an investigation by The Age uncovered a prolonged undermining of the Mental Health and Wellbeing Commission (MHWC).

Hundreds of pages of confidential documents outline the impact of budget cuts and legislative overhauls inside the MHWC, culminating in its December 2025 decision to scale back investigations into systemic failings that impact thousands of vulnerable people relying on Victoria’s psychiatric services.

In recent months, The Age has laid bare a system in crisis, with two recent youth suicide clusters, services failing to meet their targets for admitting acutely mentally unwell patients, escalating violence against workers, and the resignation of the fly-in, fly-out boss of the state’s flagship youth mental health service.

The MHWC was established in 2022 as an independent watchdog to monitor the government’s progress in implementing the mental health royal commission’s recommendations, as well as systemic issues and complaints about mental health services. Legislation demanded it be headed by four independent commissioners.

But changes to that legislation introduced to parliament on December 4, 2025, sought to replace the MHWC’s independent leaders with a single minister-appointed commissioner. New laws also limited the watchdog’s remit to investigate the government’s post-royal commission reforms and systemic failings, and instead required it to focus on complaints about individual health services.

When the soon-to-be-axed commissioners met on December 18, 2025 – a fortnight after the legislative amendments were introduced to parliament – they literally put a line through major systemic issues they understood they were losing jurisdiction to examine.

Internal records from that meeting, seen by The Age, reveal the commissioners and executives discussed their diminishing capabilities and how they would reprioritise the issues they would continue to scrutinise, and those that would instead be placed on a watch list or ignored altogether.

“Legislative changes are likely to see the remit of the MHWC focus on systemic issues arising from complaints and investigations (ie focus on service providers) likely be set out in a ministerial letter of expectations provided to the Commission by the Minister for Mental Health,” the MHWC’s December 18 meeting heard.

“The commission has a legislative and moral obligation to review these issues and progress those that warrant further exploration and align to the commission’s review function as set out in the Mental Health and Wellbeing Act 2022.

“Changes within the MHWC including budget constraints mean very limited resourcing will be available to support process to identify and prioritise systemic issues or conduct systemic reviews or inquiries.”

Through its “Interim Approach to Addressing Systemic Issues”, the meeting worked through the MHWC’s list of priority systemic issues and put a line through seven major areas it believed it no longer had the power to examine.

Those scrubbed out included: the rollout of new dedicated mental health beds for young people, particularly in rural areas; pay disparities between mental health workers amid a workforce crisis; the impact of working with children check requirements for drug and alcohol workers; and the use of restrictive practices outside the Mental Health and Wellbeing Act.

The commissioners were left with a colour-coded table of priorities, including a purple “short list” of issues they deemed suitable for inquiries in the next six to 12 months. They included difficulties accessing alcohol and drug services; patients being chemically restrained; and the misuse of hospital “code grey” security procedures.

Issues listed as blue were consigned to a “watching brief” rather than receiving immediate examination. They included the availability of existing inpatient mental health beds for young people; services not taking carer complaints seriously; legal risks when patients or staff are harmed; a review of Koori mental health liaison officers; the frequency of patients being discharged into homelessness; the use of code greys to prevent patients “absconding”; and follow-ups for people denied access to mental health services.

The priority list also included a teal category for ad hoc issues – such as requiring all mental health services to hold security camera footage for longer – which would generate a simple response, such as a letter.

The final green category would see direct requests receive an immediate response, such as endorsing another organisation’s campaign or providing a comment.

Even when it did have full powers to investigate any systemic issue the MHWC failed to launch a single own-motion investigation, the watchdog conceded in its 2024-25 annual report. As a consequence, it had pledged to identify a list of appropriate issues to examine.

After their remit was cut, the commissioners’ “Interim Approach to Addressing Systemic Issues” was intended to scale back that list further to hold the fort from December until the health minister appointed a permanent mental health commissioner.

But within a month, the MHWC’s ability to safeguard even the parts of the system it still had jurisdiction over was also buckling.

At their January 29, 2026 governance meeting, MHWC leaders shared concerns that high vacancy rates in the complaints and resolutions team were impacting performance standards, as each resolution officer dealt with between 25 and 30 cases. Mitigation controls had been put in place to address “psychosocial risks” for those staff, the meeting heard.

Brief notes from the ensuing discussion “voiced that is not a reasonable expectation for complaints and resolutions staff to continue to meet the benchmarks and performance standards set for the previous larger staffing levels”.

“AB [commissioner Anabel Brebner] emphasised the need of temporary revised benchmarks and clear messaging to staff on expectations in the current state,” the discussion notes continued.

The meeting resolved to notify the Department of Health it had moved its benchmarks to reflect its diminishing situation, and that “there is no expectation set on current staffing levels to absorb additional work to the current workload”.

When The Age this week questioned the MHWC about scaling back investigations, it conceded it had “navigated a period of significant organisational and governance change following the introduction of the new legislative framework, alongside the impacts of broader fiscal pressures across the public sector”.

In a statement, the MHWC maintained it upheld its independent role while adapting to forced changes and remained focused on handling complaints; monitoring and reporting on system performance; and reporting on the implementation of the royal commission’s recommendations.

Victoria’s new Mental Health and Wellbeing Commissioner Jennifer Black – who took up her role this week after being appointed by Health Minister Ingrid Stitt – said she was focused on working with the state government to ensure the commission was well-placed to deliver its functions and drive change.

“The commission plays an important role in protecting rights, and it is vital that it is positioned to effectively perform its core functions, to support positive outcomes for all Victorians who access the public mental health and wellbeing system,” Black said.

A Department of Health spokesperson said the MHWC remained an independent and critical part of Victoria’s mental health oversight framework.

“Recent changes strengthen leadership and accountability, focusing the commission on where it can have the greatest impact – safeguarding rights, resolving complaints and helping improve the mental health system,” the spokesperson said.

Victorian Mental Illness Awareness Council chief executive Vrinda Edan said some of the sector’s biggest problems were systemic and not necessarily visible through individual complaints.

“What’s important to us is the consequence for independent oversight. Whatever the underlying reasons for the changes, any reduction in the capacity to identify and report systemic problems should be taken seriously,” Edan said.

Phillipa Thomas, the chief executive of peak body for public and private health providers Mental Health Victoria, said the latest revelations raised concerns about the MHWC’s ability to respond to complaints, with some of the issues on short lists “alarming”.

“These documents clearly foreshadow planning for the removal of mechanisms for independent oversight and accountability of royal commission implementation and contradicts reassurances provided to the sector,” she said.

Mental Health Legal Centre chief executive Charlotte Jones said revelations that the MHWC kept a waiting list of systemic issues, rather than immediately acting or launching investigations into matters it was aware of, showed it needed an overhaul.

“Where are these investigations which should have helped prevent incidents and recommendations to raise standards? A budget of $750,000.00 per inquiry without any detail as to how this was assessed – and we can only recall one report,” Jones said.

“They were as siloed as the system they were working in. These failures highlight why we need an adult safeguarder who oversees the safeguards in the system to check these are working.”

If you or anyone you know needs support, call Lifeline on 13 11 14, or Beyond Blue on 1300 22 4636.