SA Health investigates medication errors at youth detention centre

South Australian health authorities have investigated three medication errors at the state's youth detention centre since the start of last year, amid ongoing concerns about the lack of a 24/7 health service at the site.

The errors were reported between January 2025 and October this year and involved a "chemist dispensing error with an incorrect dose", a young detainee accessing another detainee's over-the-counter medication, and a "documentation error".

An SA Health spokesperson said the errors did not cause harm.

"All incidents were thoroughly investigated and appropriate follow up action [was] taken," the spokesperson told the ABC.

While SA Health operates a clinical in-reach service at Kurlana Tapa Youth Justice Centre six days per week, operational unit staff are responsible for administering medication to the children in custody.

Last year, SA's Chief Psychiatrist and the Youth Training Centre Visitor raised concerns about the lack of a 24/7 health service at the site, writing in a joint report tabled in state parliament that the absence "undermines timely and appropriate clinical care".

They wrote there were 10 medication errors reported at the Kurlana Tapa centre between January 2024 and January 2025.

"Clinical incidents reviewed by OCP [Office of the Chief Psychiatrist] found instances where youth workers had administered medication to residents that had not had a medical officer review nor was the medication ordered for the resident and blank paper used to document medication administration times," they wrote.

"Medication charts are handwritten, and systems are fragmented, with medication ordered through local pharmacies and managed manually by operational unit staff.

"Medication management lacks clinical oversight, raising risks related to accuracy, safety, and appropriate administration of psychiatric and general medications."

Watchdog calls for round-the-clock health service

Acting Training Centre Visitor Sue Macdonald told the ABC medication errors at the centre were concerning, given some young people were on psychotropic or other "strong" medications.

The watchdog said the reported incidents could be partly attributed to human error and to the fact that medication was administered by operational staff, not health workers.

"While any medication error is a problem, I think the bigger problem is the access to healthcare for young people in the centre," she said.

"We would worry that harm could occur if it [medication] wasn't being administered correctly."

Ms Macdonald said one young person at the centre had spoken to her office about being administered the wrong medication, which prompted her office to provide feedback to centre staff.

She said since the joint report by her office and the chief psychiatrist was handed down last year, the centre had improved its systems, but it still lacked a 24/7 health service — a key recommendation of the report.

"A 24-hour, seven-day-a-week health service would go a very long way to providing a much better care environment for children are detained in the centre,"

she said.

'Reduction' in reported medication errors

According to SA Health, clinicians at Kurlana Tapa provide centre staff with "regular medication chart reviews, including clear instructions for administration".

A department spokesperson said several improvements had been made since the joint inspection report was handed down, including improved prescribing and blister pack checking processes, updated medication management procedures, and ongoing education and visual alerts to support workers in administering medication.

"This has contributed to a reduction in reported [medication error] incidents," they said, adding that "medication errors very rarely occur within the health centre".

"The external commercial pharmacy (contracted by Department for Human Services) has solid systems in place to quickly identify and rectify potential errors to ensure the safety of consumers."

SA's Chief Psychiatrist, Associate Professor Melanie Turner, said the forensic Child and Adolescent Mental Health Service (CAMHS) offered "ongoing care" for children at Kurlana Tapa to support medication review and changes, alongside a visiting GP and nursing staff.

"CAMHS provides specialised mental health support for children and young people and is well-placed to support the centre," she said.

Ms Turner said she supported efforts by CAMHS to fill vacant clinician positions at Kurlana Tapa.

After recent hires, the centre will employ 5.2 full-time equivalent clinicians by mid-November.

Women's and Children's Health Network CEO Julie Waddington-Powell said the network was recruiting to bring the centre to its "full capacity" of 6.75 full-time equivalent clinical staff.

But she said recruitment was challenging, due to a national shortage of mental health clinicians.

"In addition to the CAMHS in-reach and specialist assessment support, the centre is supported outside of the CAMHS hours by the Women's and Children's Hospital through the emergency department and SA Ambulance Service," she said.

"Other CAMHS specialist allied health staff provide assessments as required for speech pathology, occupational therapy and advanced clinical psychology."