Save our Paramedics
from the enemy within
Welcome to the website.As a survivor of Ambulance NSW, I experienced and witnessed this culture first hand, at all levels and in all sections of the organisation. Many of us believed after each successive Parliamentary Inquiry that things would change but sadly this has never eventuated. There has never been the will, capacity or insight in senior management of Ambulance NSW to fix these issues and it would appear that the NSW Parliament (after 3 inquires that all concluded the same cultural issues); lacks the power to ensure cultural change.
This site is to support the campaign to achieve accountability, justice and real change in the toxic culture inside Ambulance NSW. A culture that remains powerful in the organisation after three Parliamentary Inquiries. The organisation is chronically infected with bullying, harassment and discrimination. This campaign and website is also dedicated to the Paramedics that have lost their lives, health and careers at the hands of the organisation they trusted. I believe that real and lasting changes will only be achieved by a Royal Commission into Ambulance NSW to disclose the true magnitude of the issues and hold those to account that have allowed this culture to prosper in this valued service. Apologies and promises are not enough!
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What conclusion did the recent Parliamentary Inquiry come to?
“Some eight years after the last Legislative Council inquiry into bullying in NSW Ambulance, it was immediately apparent to this committee, based on the fifty or so confidential and non-confidential submissions we received from Ambulance staff, that bullying and harassment remains a serious problem there, and that the organisation’s complaints handling systems are dysfunctional and failing NSW Ambulance employees....The [Ambulance]executive also did not seem to appreciate the fundamental dynamics of authority and trust at play in the organisation: the power dynamic that leads to bullying and renders a victim even more vulnerable; the extraordinary inner resources, trust in the system and support that it takes for a victim to escalate a matter up the line; and the lack of trust that NSW Ambulance staff currently have that their bullying matter will be dealt with fairly and effectively. It is very clear to the committee that such trust is especially lacking with regard to the Professional Standards Unit.” – Parliamentary Inquiry Report 2018
“Despite previous parliamentary inquiries and recommendations identifying this problem, NSW Ambulance have been unable to eradicate this scourge[bullying]…the problem … is that this leaves dedicated officers mentally and physically broken. They are often robbed of the job they love, their relationships suffer, and, tragically, some attempt or are successful in committing suicide …”
Parliamentary Inquiry Report - 2018
Parliamentary Inquiry Report - 2018
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the Premier to initiate a
Royal Commission into NSW Ambulance
Note: this petition will be followed by a formal petition to be lodged in the NSW Parliament
the Premier to initiate a
Royal Commission into NSW Ambulance
Note: this petition will be followed by a formal petition to be lodged in the NSW Parliament
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Updates to the campaign
Paramedics in Crisis
And they said the problems with NSW Ambulance were just with rogue individuals. Now another two senior managers have been stood down for the same behaviour.
Be very careful, this is the tactic used after the suicide of Tony Jenkins. They tried to blame him for a number of missing drugs and even labeled him an addict i.e blame the individual instead of the organisational failure. There is still Fentanyl missing and the Police proved it wasn't Tony Jenkins who took it.
These two managers deserve to lose their jobs but remember, the organisation and its senior management (including the so-call 'Ethics and Standards Unit") promoted these individuals into their positions, supported their activities for years, and defended them when they were accused by staff of violence and bullying.
Ask yourself. can the ASNSW keep saying it is rogue individuals and once they are excised, the system will be perfect ...staff stopped believing this lie years ago. Apparently, the only people who still believe this crap are Brad Hazzard, the NSW Parliament, and the ICAC.
And they said the problems with NSW Ambulance were just with rogue individuals. Now another two senior managers have been stood down for the same behaviour.
Be very careful, this is the tactic used after the suicide of Tony Jenkins. They tried to blame him for a number of missing drugs and even labeled him an addict i.e blame the individual instead of the organisational failure. There is still Fentanyl missing and the Police proved it wasn't Tony Jenkins who took it.
These two managers deserve to lose their jobs but remember, the organisation and its senior management (including the so-call 'Ethics and Standards Unit") promoted these individuals into their positions, supported their activities for years, and defended them when they were accused by staff of violence and bullying.
Ask yourself. can the ASNSW keep saying it is rogue individuals and once they are excised, the system will be perfect ...staff stopped believing this lie years ago. Apparently, the only people who still believe this crap are Brad Hazzard, the NSW Parliament, and the ICAC.
SafeWork takes NSW Ambulance to court over paramedic Tony Jenkins' death
Finally and after 2 years of lobbying, the Jenkins family has received the news that NSW Ambulance will have to answer to legal action taken by the WHS authority concerning the death of Tony Jenkins; and more specifically the role ASNSW played in causing his suicide.
The Cover-up Continues - read the full story
Report is critical of NSW Ambulance in the death of Tony Jenkins, but the lies still continue....
PARAMEDIC Tony Jenkins was treated for work-related post traumatic stress nearly 15 years before he took his own life in 2018 after he was left to drive home alone following NSW Ambulance accusations of illicit opioid use, medical records show. The ambulance service has taken disciplinary action against some senior employees after Mr Jenkins was questioned, without an independent support person, at a meeting called without warning on April 9, 2018, only hours before his death, about allegations he used ambulance-issue Fentanyl from Hunter ambulance stations. There was "a failure in the decision-making process" about the nature of the meeting, the policies to be applied and "the manner in which Mr Jenkins' legal rights and welfare were to be protected", external reviewer Kylie Nomchong, SC, found in a report to NSW Ambulance chief executive Dominic Morgan. A summary of medical records provided to Mr Jenkins' widow Sharon in early September, that forms part of a NSW Police brief to the NSW Coroner's Office, shows a history of work-related trauma and treatment before the April, 2018 meeting, including a 2004 post traumatic stress diagnosis. While NSW Ambulance senior staff asked Mr Jenkins about his welfare during the meeting and offered support, Ms Nomchong found that file notes "inappropriately" written "retrospectively" and backdated after his death "were drafted to over-emphasise those welfare steps". The summary of Mr Jenkins' interactions with Hunter doctors and hospitals and NSW Ambulance employee services "clearly shows he used the services offered to him", and raised questions about allegations he self-medicated with Fentanyl taken from Hunter ambulance stations, Mrs Jenkins said. A toxicology report found Mr Jenkins had no Fentanyl or other drug in his system when he died. "The picture they've tried to paint of him is not consistent with the medical records or with the evidence that is available," she said, while repeating her view that an inquest is needed to provide answers about her husband's death. "If we hadn't said anything that would be what everybody's left with about Tony, and that's not right." Mr Jenkins, 54, took his own life about two hours after he was dropped off to his car, alone, by a senior NSW Ambulance officer on April 9, 2018 part-way through his shift after the meeting over the Fentanyl allegations. An initial NSW Ambulance investigation said there was ";a sense of urgency to meet with"; Mr Jenkins on April 9 after allegedly tampered Fentanyl bottles were found that morning at the station where he worked. He was questioned after an audit seven months earlier identified him as the second highest paramedic Fentanyl administrator in NSW, but a subsequent review without Mr Jenkins' knowledge found "no evidence" of "mis-use"and it "did not identify any concerns regarding the paramedic's usage". In a letter to Mrs Jenkins in June after Ms Nomchong's external review NSW Ambulance chief executive Dominic Morgan blamed a drafting "mistake" for a "regrettable error" in an initial ambulance root cause analysis report in 2018 that incorrectly claimed Mr Jenkins handed two syringes of morphine to senior officers at the April 9 meeting. Mr Morgan did not explain how the "mistake" was made but said Ms Nomchong found the syringe allegation in the root cause analysis report was "not consistent with the records advanced by"senior officers at the meeting. Mr Morgan said Ms Nomchong found Mr Jenkins should have been driven home after the meeting, and not dropped at his car to drive home alone, but "this was not a causal factor in Mr Jenkins' suicide". A summary of Mr Jenkins' medical records compiled by police shows a medical examination when he started with NSW Ambulance in 1990 noted he had no drug or alcohol problems and was not suffering from any form of mental illness . By 1992 he was experiencing "stress and fatigue" from his Lake Macquarie to Sydney commute for work while raising a young family, and he was twice issued with WorkCover certificates for time off in 1998. He was issued with two more WorkCover certificates in 2004 and diagnosed and treated for post traumatic stress after a "violent and threatening situation"during a work call-out, which was exacerbated when he was sent to the same address after returning to work, the medical summary shows. A doctor reported Mr Jenkins's "frustration with being exposed unnecessarily to dangers at work" and his anger at NSW Ambulance for "constant exposure and inadequate information provided to officers". By 2012 a corporate support service noted Mr Jenkins was "becoming worried about other people's sad circumstances" requiring a plan to "protect self from others' circumstances", but he had a low risk of suicide. The medical summary showed treatment for asthma and prescribed drug therapy for depression with positive results until the end of 2017. A doctor who prescribed Panadeine Forte and Valium on December 19, 2017 for a flare-up of back pain has made a statement to police about her interaction with Mr Jenkins where he made no mention of depression and said he was not taking other medications. Mrs Jenkins said Ms Nomchong's external review answered more questions but her family was not happy with NSW Ambulance's responses and "that's why we're hoping to get more answers from an inquest"."It's important it is held," Mrs Jenkins said. "The way this has been handled by NSW Ambulance affects everyone else because there are a lot of Tonys around who have experienced work-related trauma". In his letter Mr Morgan said NSW Ambulance had already taken "significant action in response to these issues by introducing a more robust risk management process". "From these tragic events, NSW Ambulance recognises and accepts that more is needed to both support staff members who may be at risk or present a risk to themselves/others as well as to provide greater guidance to senior managers tasked with responding to such matters," Mr Morgan said.
Newcastle Herald - 24th September 2019
Newcastle Herald - 24th September 2019
MP supports formal petition to the NSW Parliment
JUL 10, 2018 — We now have an MP willing to present a formal petition to the NSW State Parliament. We need a min of 500 signatures and if we achieve 10,000 it has to be considered on the floor. Details of how to get the petition to sign coming soon. In the meantime please keep spreading the word and gathering support. We need real change not promises. Critical review of inquiry findings
JUL 30, 2018 — Read a critical review of the latest recommendations of the Parliamentary Inquiry. The important points, what was not addressed and the barriers to change that ASNSW senior management still do not understand or acknowledge.
AUG 7, 2018 — On Monday 6/8/2018 the Daily Telegraph published an article titled – “CALL TO SAVE THE SURVIVORS – call for phone counselling service just for emergency services”
While it is good that they brought the subject of the bullying culture in the Ambulance Service of NSW once again to the public’s attention, unfortunately the figure quoted was 29% of staff experiencing bullying usually by management (the highest of any emergency service), the actual number presented to the inquiry by the Paramedic Association is 70%. An initiative to provide specialised psychology support services for emergency service workers is great, it does not however address the fundamental issue of a toxic and pervasive bullying culture. Prevention is always better than cure. The main cause of psychological injury is the lack of organisational support and bad management rather than simply traumatic events. By simply providing psychology services, we will just be trying to manage what has already been damaged. We need to fix the actual problem! This petition to initiate a Royal Commission into the NSW Ambulance Service will be followed by a formal petition to the NSW Parliament. Everyone should consider if an apology and promises after 3 separate inquiries (with the same finding of a bullying culture) will change anything for our brave Paramedics. History tells us that public apologies and promises to make change from political figures (even from Prime Ministers let alone the CEO of NSW Ambulance), do not necessarily result in significant change or real solutions. It is in your hands to help them now by forcing change and encouraging your networks to sign up. Please share this petition with as many residents and influencers in NSW as you can. Standing by while this culture continues is condoning the actions of bullies. Paramedic’s suicide points to crisis in Australian ambulance services
By John Mackay and Cheryl Crisp 9 July 2018The suicide of a 28-year veteran paramedic in the Hunter region of Newcastle, a major regional city north of Sydney, further exposes the worsening situation in Australia’s under-staffed and over-stretched ambulance services. In early April, Tony Jenkins, 54, took his own life following a meeting with senior management in the New South Wales (NSW) Ambulance Service. The meeting was called to discuss alleged tampering with 16 vials of the opioid painkiller Fentanyl. Many unanswered questions surround that meeting. Jenkins was accused of criminal acts—stealing Fentanyl—but the clear guidelines for all management-staff meetings were flouted. Jenkins was given no advanced warning of the meeting, and had no support person present. No minutes were taken of the proceedings, nor was the meeting recorded. According to management, Jenkins admitted to theft, saying he was relieved it had been discovered because he could then seek help. Despite this, he was dropped off alone by a senior ambulance officer. Jenkins did not finish his shift. He drove straight to a local hardware shop where he purchased the equipment for his suicide. The paramedic was still in his uniform when his body was found early the next morning in bushland near his home. Within a few short hours of his meeting with NSW Ambulance management, he was dead. A toxicology report found Jenkins did not have Fentanyl in his system when he died. His family insists there were no prior triggers or clues to his decision to take his own life. After almost three months of obfuscation by NSW Ambulance and a sustained campaign by Jenkins’ family for answers regarding his treatment and death, NSW Ambulance Commissioner Dominic Morgan issued an unprecedented apology to “all NSW paramedics.” Morgan did not directly refer to Jenkins when he conceded that NSW Ambulance had “not always looked after its staff as well as it should have.” He said the service had “terribly let down some staff, and others we have completely failed.” Morgan’s televised address stated that in his discussions with paramedics during his two years in office, the three issues they said needed change were increased staff numbers, mental health support and protection against occupational violence. It was precisely on these issues Jenkins had gained a well-earned reputation for campaigning with management on behalf of his fellow workers. His daughter, Kim Jenkins, told the Newcastle Herald that the contents of her father’s work locker following his death, revealed “a mountain of correspondence about Dad trying to get things changed.” This particularly related to dangerous jobs he and his colleagues were sent to attend, about which they were provided with little or no information. Jenkins felt he was “waging a losing battle” and the necessary changes were not occurring fast enough. In the Sydney Morning Herald, his other daughter, Cidney Jenkins, wrote: “How could a man who preached about his good fortune, his loving family and his remarkably happy life, be driven to take his own life, without warning. Where was the depression? Where was the melancholy? Where were the signs? There were none—other than a 28-year gig with the NSW Ambulance.” Her article made clear the lack of support provided to paramedics by NSW Ambulance. She wrote: “Many of us assume that the most traumatic part of a paramedic’s job is what they find when they respond to an emergency call. What many of us fail to consider is what happens to paramedics once they leave a scene. What sort of support do they receive? Where do they go after attending a fatality? More often than not, their next stop is another job.” Jenkins’ suicide is the third by paramedics in the Hunter region in a decade. It highlights the shockingly high rate of suicides among ambulance officers—double that of the general population. His death came six months after yet another NSW government inquiry into workplace bullying in the emergency services. This confirmed what had already been established previously: NSW Ambulance has significant problems with bullying, including treatment of staff by managers. Australian Paramedics Association (APA) secretary Steve Pearce, who gave testimony to the inquiry, said: “Some managers are using performance management … and job selection as a means of selectively punishing those that displease them.” He reported that some managers ignored or misused policies designed to protect workers and turned a “blind eye” when intimidating behaviour was reported. Steve McDowell, a former paramedic with post-traumatic stress disorder (PTSD), founded a support group for ambulance officers. He told the inquiry there was deliberate “obstruction” of complaints of bullying and harassment to prevent them being escalated to the Professional Standards Unit. Professor Carlo Caponecchia of the University of NSW, who presented a submission to the inquiry, reported: “Research shows that people in emergency services are not so much stressed by what they see on the road, it’s what happens to them back at the depot, back at the station, in relation to their colleagues, in the support they get or they don’t get from the service they are employed [by].” Paramedics and mental health experts alike say there is a lack of support from management, an absence of debriefing procedures, and a denial of the need for counselling services and the time to engage them. This has resulted in a toxic and alienating environment, with antagonistic relations between staff members. Chronic under-staffing and 12-hour shifts that routinely stretch to 14 or more hours increase the stress, with an emergency call being made to NSW Ambulance every 28 seconds. In 2016, only 80 new paramedics were hired statewide, not enough to overcome shortages. At the time, APA secretary Pearce told the Sydney Morning Herald: “Lives are being put at risk by the NSW government, which has failed to address this critical shortage of paramedics over several years.” Exhausted paramedics were “doing so much overtime it’s disturbing” and the additional recruits would be “a drop in the ocean.” Health Services Union president Gerard Haynes told the inquiry that the service was “at least 1,000 people short,” but the unions covering paramedics have done nothing to oppose the constant erosion of staff and conditions. Industrial action has been called off repeatedly over the past decade, allowing management to impose onerous shifts and workloads. In 2017, the unions allowed ambulance stations to be closed in working-class areas of Sydney—replaced by “super stations”—leading to increased response times because greater distances must be travelled. Paramedics who opposed the closures, warning that lives would be put at risk, were abandoned and isolated by the unions. The NSW ambulance service employs 4,500 staff, with 90 percent in operational roles, such as paramedics. In late 2017, a NSW Auditor General’s report revealed that between 2012-2017 the demand for ambulance services grew more than 2 percent every year. Last week, the state Liberal government said 200 new paramedics would be hired in 12 months and a total of 700 over four years. But only 25 new ambulances would be brought into use, so the shortfall would remain. This promise, made less than a year before a state election, may never be implemented. APA assistant state secretary Gary Wilson told the WSWS: “NSW Ambulance does not have the capacity to train an extra 200 paramedics in 12 months.” Years of budget cuts by governments, both Liberal and Labor, are responsible for the impossible conditions that led Tony Jenkins and others to take their own lives. SEPTEMBER 29 2018 - Newcastle Herald
A NSW Ambulance investigation of paramedic Tony Jenkins' suicide has raised serious questions. Joanne McCarthy THE family of Lake Macquarie paramedic Tony Jenkins has demanded an apology from NSW Ambulance for inferring he was a drug addict following his suicide in April, after a secret review three months before his death concluded there was “no evidence” he “mis-used” restricted NSW Ambulance medications.
The family is even more determined to push for a public Coroner’s inquest after a NSW Ambulance investigation of events leading up to Mr Jenkins’ death provided no solid proof to back allegations 38 Fentanyl vials at four Hunter ambulance stations were tampered with, or that Mr Jenkins was responsible. Fentanyl is a synthetic opioid painkiller 100 times more potent than morphine. The investigation instead found NSW Ambulance carried out no routine tracking of Fentanyl usage; that weekly “integrity check” audits of Fentanyl and other restricted medications were lacking and varied from station to station across the state; that secure drug safes were “frequently not closed” and drugs were “handed over” from shift to shift; compliance with dual signing out of restricted drugs varied; and “a culture of trust and mateship” resulted in regular checking procedure “violations” and “routine deviation” from restricted drug policies across NSW. The investigation also “could not confirm if other staff were or were not involved with medication tampering” at Hunter stations. Mr Jenkins’ family wants an inquest to explore why he was targeted on April 9 after a morning shift identified allegedly opened Fentanyl at a Hunter station where he worked. NSW paramedic Tony Jenkins had a history of standing up for reforms in NSW Ambulance. The NSW Ambulance investigation said there was “a sense of urgency to meet with” Mr Jenkins on April 9 but cites an audit seven months earlier identifying him as the second highest paramedic Fentanyl administrator in NSW as the reason he alone was questioned. This was despite a subsequent review in January, without Mr Jenkins’ knowledge, that found “no evidence” of “mis-use” and which “did not identify any concerns regarding the paramedic’s usage”. Mr Jenkins committed suicide on April 9 less than two hours after he was dropped off, alone, by a manager following an unscheduled meeting part-way through a shift where the manager alleges Mr Jenkins admitted he “relied on Fentanyl” but it was “out of control”. Despite a NSW Ambulance file note of the April 9 meeting alleging Mr Jenkins admitted replacing used Fentanyl vials with a saline solution, a NSW Ambulance investigation report provided to Mr Jenkins’ family on September 7 was silent on any testing of the 38 vials or conclusions about the tampering allegations. The investigation found collection of the vials on April 9 from four Hunter stations via an ambulance vehicle to an “incorrect location” did not follow policy for the transportation of suspected tampered medications. Mr Jenkins’ family said the failure meant the vials could not be relied on as evidence because of chain of custody questions. An autopsy found no trace of Fentanyl in Mr Jenkins’ body at the time of his death. The two-page report of the April 9 meeting, written by the manager who dropped Mr Jenkins off alone after the meeting, does not record that he was asked if he had taken Fentanyl before his shift. The file note alleges Mr Jenkins carried two morphine syringes on his person into the meeting and said he’d drawn them up intending to use them on himself. His family slammed the allegation as implausible and unbelievable. Answers: Sharon Jenkins with daughters Cidney (left) and Kim. The family wants answers about events before paramedic Tony Jenkins' death on April 9. The NSW Ambulance investigation also relied on reports by “a number” of unidentified paramedics of Mr Jenkins “appearing sleepy, a series of near miss accidents whilst driving and clinical records not completed to his usual standard” in the months before his death to justify a conclusion that “these behaviours were early warning signs of a possible addiction to Fentanyl”. “Their warning signs of a possible addiction to Fentanyl are so vague they could also describe someone who was simply lacking sleep,” Mr Jenkins’ nephew Shayne Connell said. Mr Jenkins’ family said NSW Ambulance had not responded to requests for formal reports of the “near miss accidents”. His family rejected that he displayed any behaviour fitting the alleged admissions he was “out of control”. The NSW Ambulance investigation report said the service received a state-wide Fentanyl audit report in September, 2017 commissioned because of an “unrelated matter” involving the prescribing habits of two NSW paramedics. The audit identified Mr Jenkins as the second-highest administrator of Fentanyl in NSW. It was not until January, 2018 that a second secret review of Mr Jenkins’ Fentanyl administration, conducted without his knowledge, concluded no evidence of mis-use but recommended “education in relation to the Fentanyl pharmacology”. The investigation report found the education “did not occur”. Mr Jenkins’ widow Sharon, daughters Cidney and Kim and nephew Shayne Connell described NSW Ambulance comments after his death and a subsequent internal investigation as a “disgraceful attempt to posthumously defame and discredit” Mr Jenkins in an attempt to avoid responsibility for events leading up to his death and major deficiencies in the organisation’s systems. Devastated: Sharon Jenkins with one of her late husband Tony's paramedic uniforms. The devastated family wants a public coronial inquiry into his suicide. Picture: Max Mason-Hubers. A NSW Ambulance statement after Mr Jenkins’ death included concern that a paramedic “could find themselves so desperate that their only option was to turn to drugs and addiction”. “They’re trying to portray him as this devious drug addict who’s put the public at risk. They’re blaming him for what happened rather than look at their duty of care to someone they allege was drug tampering, and an addiction for which they have no evidence,” said Mrs Jenkins. The family was outraged at the opening statement of the NSW Ambulance investigation report which was an examination of “the circumstances whereby a paramedic inappropriately accessed restricted medications from NSW Ambulance, over an extended period, and the subsequent management of the matter once identified”. “They have no evidence to say any of those things. They’ve provided no evidence to make that statement or even that there was tampering,” Mr Connell said. “If they’d tested those vials and it came back with salt solution in them don’t you think they’d be rushing to us with those results? But no. Five months after they publicly blamed Tony for using NSW Ambulance Fentanyl we don’t know where those vials are or what’s in them. “How do you do a root cause analysis of a critical incident into the death of an employee without even saying what’s in the vials? It’s like they’re trying to do a root cause analysis with no evidence and no results. Based on what they’ve given us it’s more like they’ve tried to write a suicide note on Tony’s behalf by portraying him as a drug addict when available evidence says the opposite.” Mr Jenkins’ family said information in the file note purportedly said by him during the April 9 meeting was factually incorrect, including that he had had a drinking problem, that his wife was a manager at Coles and that he had been treated by his GP for depression. The mistakes raised real doubt about what was said at the meeting and the reliability of the document which was produced without minutes or notes being taken during the meeting or an independent witness, the family said. A NSW Ambulance spokesperson confirmed the circumstances of Mr Jenkins’ death were being investigated by NSW Police on behalf of the NSW Coroner’s office. “Therefore NSW Ambulance can make no further comment pending the outcome of those investigations and a coronial inquiry,” the spokesperson said. “NSW Ambulance offers its sincere condolences to the Jenkins family and continues to offer support during this difficult time.” Read full story https://www.theherald.com.au/story/5670221/paramedics-family-demands-apology-over-drug-allegations/?cs=12 The transcript from the Federal Senate Inquiry into mental health conditions experienced by Emergency Service Workers.
Some excerpts: Australian Paramedic Association about a recent survey: “Our respondents said that 73 per cent had faced bullying and harassment within the workplace. 79 per cent of complainants indicated they did not feel that their complaint was taken seriously by New South Wales Ambulance management, and 59 per cent of complainants indicated that their complaint was left totally unresolved by New South Wales Ambulance management.” Senator: “At the outset, throughout your submission, you are sometimes quite critical of the process of New South Wales ambulance. What's your relationship like with New South Wales ambulance? Part of the reason I ask that is because they were invited today and they actually decided not to come, which I'm very concerned about because I feel as if they care about their workers and they should've come along to answer questions.” Senator: “Again, I'm really concerned that the New South Wales ambulance chief is not here today, and I'll probably say to every witness. I'm really annoyed that they haven't bothered to show up to tell us how good or bad they are because I think everyone—the paramedics out there on the beat—deserve to hear from their employer about what they're doing to overcome some of the issues.” Senator: “This is something we have seen over and over again— paramedics and first responders taking their own life. There is always a question mark about whether it was related to the job; coincidentally, more often than not it is. But there doesn't seem to be a clear correlation between the two. If there was, I would hope that things would happen a lot quicker within an organisation to try and help those people.” Senator: “I just happened to be watching a bit of TV in a motel room the other night and saw a British program about first responders. I noticed during the ads for that program that New South Wales Ambulance is doing the same sort of show on commercial TV. In that television program—we are talking about commercial TV, and they cut and snip bits out of it—are we going to see what is really like in New South Wales Ambulance or is it going to be a glorified version of what people want to see and what the shows want to rate things at?” |
Parliament releases finding of 3rd inquiry
JUL 25, 2018 — The Parliamentary Inquiry into bullying, harassment and discrimination in Emergency Services was released yesterday. No prizes for which service has the worst record. As predicted, two previous inquiries have failed to force cultural change in ASNSW and we should not trust ASNSW that "this time it will be different". The best predictor of future behaviour is past behaviour and the Ambulance CEO in the inquiry demonstrated a complete lack of insight into the issues so what will change? Allowing the ASNSW to "fix" the issues themselves is a mistake that has already been made twice, without success. Independent experts at the inquiry made it clear that cultural change is only possible through external means not internal policy change. The report re-enforces the need for a Royal Commission into ASNSW. Then and only then can the truth be exposed, the toxic culture exposed and change forced on the organisation. Please support this petition and stay tuned for details of the formal petition details necessary to have it debated in the NSW Parliament. Read the report of the inquiry on the link below but be prepared to be outraged.
Calling all current and former NSW Ambulance staff
Our petition for a Royal Commission into ASNSW has been steadily growing and it is obvious that many who have signed up have personal experiences of the toxic culture that has gone unchecked for many years. Destroyed lives, suicides, retirements, denied justice and relationship breakdowns all seem to be common results of this culture never being adequately addressed. You must ask yourself if you truly believe that after three parliamentary inquiries, followed by the same promises by ASNSW CEO's, anything will actually change? History tells us that CEO promises and parliamentary inquiries have no power to make the fundamental changes that need to happen. As a current Paramedic you are only one incident away from having the organisation you trust, turning on you and trying to destroy your career and well-being. This happens and will continue to happen until those who perpetuate this culture are brought to account. Former Paramedics all have a common experience, in that they are all shocked by how they could be treated by an organisation that they gave so much to and they thought were valued in. As CEO Dominic Morgan was making promises about a "bright future" Sharon Jenkins (widow of the late Paramedic Tony Jenkins) was being presented with a falsified record of the interview that management had with her husband before he took his own life. Tell me anything has changed! In order for this petition to be successful and provide a catalyst for a formal petition to the NSW Parliament we need support. I urge you to share this petition with your friends, colleagues, former colleagues, family, local members, media and the community. Real change cannot happen without real accountability. Request to ANSW CEO - Mr Dominic Morgan
By its own (though grossly underestimated) statistics, 1/3 of bullying in NSW Ambulance is perpetrated by senior management.
As proof of a commitment to actual change, and that the promises made are genuine, we ask the CEO of NSW Ambulance, Mr Dominic Morgan to disclose to the people of NSW the number of senior managers that have faced formal disciplinary action and/or been dismissed for unacceptable behaviour since the public apology and statement of a “turning point in the organisation” on 25th June 2018? If you believe the answer will be “zero”, it is definitely time for a Royal Commission. Please encourage your friends to sign this petition and demand accountability. Response to report aired by ABC 7.30 with Leigh Sales
Paramedics stealing lethal opioids to help them cope with trauma Originally posted Thu 24 May 2018, 8:54pm Updated Fri 25 May 2018, 10:06am Retrospective analysis of this media report, in light of what we now know…[ ] Investigations around the country have found officers emptying vials of the potent painkiller Fentanyl and switching them out for saline, or worse still, tap water. In NSW, where the problem is at its worst, the ambulance commissioner has ordered for a state-wide investigation into drug protocols and random drug-safe audit. Transcript LEIGH SALES, PRESENTER: There is alarming new evidence that paramedics are stealing lethal opioids from their workplaces to cope with trauma. [the reasons for possible abuse include trauma i.e. emergency incident, however bullying and abuse at the hands of senior management is also a major factor] Investigations around the country have found officers emptying vials of the potent painkiller fentanyl and switching them out for saline or worse still, tap water. In New South Wales where the problem is at its worst the Ambulance Commissioner has ordered a state-wide investigation into drug protocols. [this process is designed to find individual scapegoats in certain workgroups or individuals rather than an attempt to improve security] Fentanyl tampering has serious implications both for patients in crisis and paramedics themselves. [any Fentanyl abuse is a symptom of a much larger problem]. SHAYNE CONNELL, NEPHEW: If you think about when you call 000, it's at the absolute crisis point in your life and that's an average day in their work. FRANK VAN DE MORTEL, PSYCHOLOGIST: They are constantly in a state of emergency and they are constantly responding to emergencies. (Extract from a 000 call) OPERATOR: ... emergency? CALLER: My husband's having a heart attack ... (End of extract) HAGAR COHEN, REPORTER: The daily grind for a paramedic is stressful and unpredictable. The potential of being exposed to trauma is constant. [and in NSW particularly, more importantly stress from poor and abusive management] MICHAEL HAWKES: You see lots, a lot happens to you when you're out. It distorts your mind. HAGAR COHEN: With such easy access to extremely potent addictive drugs and high rates of PTSD, some paramedics have resorted to taking medications [a growing number have resorted to suicide. Is this less or more of a litmus test of a greater issue than substance abuse?]. FRANK VAN DE MORTEL: It's not about getting high, it's not about achieving any sort of sense of an unreal type of feeling, it's about just being able to function. There are way too many people suffering and not just the paramedics, but their families. I think we have been at a crisis point for a very long time [staff of NSW Ambulance recognise that they are at a crisis point, on several grounds, the only people who cannot see this are senior management. This was clearly demonstrated in the recent NSW Parliamentary Inquiry] HAGAR COHEN: On Monday, April 9th this year, Tony Jenkins arrived for his shift at the Belmont ambulance station in the New South Wales Hunter region. He'd served New South Wales ambulance for 28 years. SHARON JENKINS: It was a worthwhile profession. It had substance to it. He could be proud of something he did daily and that would have been why he really loved to do it. HAGAR COHEN: Tony Jenkins had been exposed to many traumatic events over the years. [Tony Jenkins had also made numerous complaints to management about a variety of problems including substance abuse, which had been disregarded]. SHARON JENKINS: He used to feel anxious going to jobs because you don't know what it is when you get there, you don't know who is going to be there, what is the scene, so there was always a bit of anxiety. HAGAR COHEN: At 4:30pm Tony Jenkins was called in to a meeting at the regional headquarters in Newcastle. SHARON JENKINS: They said that he'd been called in to a meeting, that the content was because he had been self-medicating. CIDNEY JENKINS: When dad came in, he said that he knew why he was there and he then said that he was relieved because he knew that he needed help. [we now know that there were no traces of Fentanyl found in Tony’s system after his death]. HAGAR COHEN: In the meeting, Tony Jenkins was confronted about anomalies in the fentanyl supplies at his station. Fentanyl is a potent opioid used for extreme pain relief. Sixteen vials had been compromised, suspected of being emptied out and secretly replaced with saline. The Police had been notified that morning. [we now know that the Police failed to find any forensic evidence to support the claim that Tony was responsible for stealing Fentanyl. It is likely that this claim was a “set-up” by Ambulance NSW management to find a scapegoat for a wider problem and bullying behaviour] KIM JENKINS: Since then, we've found out for one, that each vial contains a huge amount. Even though it's a small vial, the amount that is contained in that vial is enough to kill a person. SHARON JENKINS: He would have felt isolated, humiliated definitely but after 28 years, he was just someone that needed help. [the support that Tony needed was not provided before, during or after the incident to his family. As evidenced by the actions of ANSW after his death, Tony was demonised to point where he felt his only option was to take his own life] HAGAR COHEN: The meeting finished at 6:15pm and Tony Jenkins was driven back to his station. From there, he left alone. SHARON JENKINS: I was in bed and I looked at the clock, 12.30 and I thought, I wonder. I texted him, "are you still at work" and I was confused because I knew something was up. HAGAR COHEN: The next morning, police and New South Wales ambulance staff visited the family home [ANSW delayed the news of her husband’s death, keeping it from Sharon along with information that he was missing since leaving work]. SHARON JENKINS: And they came in, it was about five past seven and just said that they'd found him. He was deceased and I didn't believe them. CIDNEY JENKINS: We know that it was a trigger. He left that meeting with the direct intention of doing what he did and he didn't come home and think about it. He did it straightaway. [to date ANSW has not provided a truthful account of the “meeting”. While they conducted to ‘root cause analysis”, the outcome protected the actions of ANSW and demonised Tony. There has also been no apology from ANSW but excuses for their failure]. SHARON JENKINS: There was no notes, no witness, no minutes, no recording. Why would you do it like that? Why wasn't it done correctly? [ANSW has defended the actions of the managers, despite this being against procedure. All recollections of the meeting have conveniently supported the view that ANSW did nothing wrong]. HAGAR COHEN: New South Wales Ambulance Commissioner, Dominic Morgan, has met with the Jenkins family. DOMINIC MORGAN, COMMISSIONER, NSW AMBULANCE: From my understanding of Tony Jenkins, he was this well-respected, well-regarded professional and it concerns me greatly to think that a person with that reputation could find themselves so desperate. [these statements made by Dominic Morgan are particularly offensive to the Jenkins family. Mr Morgan did not “know” Tony Jenkins, nor did he respond to any of his complaints. Tony’s reputation has only been sullied by ANSW so as to provide a scapegoat for systemic problems with management bullying and substance abuse] SHAYNE CONNELL: Tony had 30 years' worth of cumulative trauma in the ambulance. He then had what could have been up to 12 months' we're told, worth of self-medication that went unchecked and unnoticed. The levels of failure of duty of care here, are so clear. [ANSW has failed in its duty of care both to Tony and to his family]. HAGAR COHEN: Do you believe that the New South Wales Ambulance Service failed its duty of care? DOMINIC MORGAN: I think everybody at some level thinks that they've failed when such a respected individual ultimately takes their own life. This is an absolute tragedy. [this question has not been answered by Dominic Morgan. Only “thinking” you have failed and failing as an organisation are two separate issues. Blaming the individual is standard practice by ANSW for anyone who suffers injury, mental or physical at work. This is done to protect the ‘reputation” of ANSW and to minimise liability]. HAGAR COHEN: The case of Tony Jenkins is not a one-off. The ABC has obtained evidence that fentanyl theft, tampering and abuse has reached alarming levels around the country with ambulance services in at least four states - New South Wales, Queensland, Western Australia and Victoria - raising concerns about fentanyl tampering in ambulance safes. Freedom of Information documents reveal deeply concerning evidence of almost 100 investigations into paramedics allegedly misappropriating drugs of addiction around Australia. New South Wales had the largest number of cases where all up there were 36 completed investigations. [Fentanyl abuse is not the actual issue and it cannot be solely blamed on incident trauma by rouge individuals. There is also a huge body of evidence around bullying, physical and sexual abuse, discrimination and harassment by senior management that is being sustained and protected by continually blaming “abuse”, “rouge individuals” and “incident trauma’]. (Question to Dominic Morgan) Is the ambulance service at crisis point? DOMINIC MORGAN: I don't believe the ambulance service is at crisis point. [and here in lies the problem. The recent Parliamentary Inquiry was also astonished that Dominic Morgan lacked the insight to see the gravity of the situation the organisation is in. ANSW’s answer to everything is that they have the will, capacity and insight to solve all issues internally. This has never and will never be true, particularly when referring to the culture of ANSW]. What I think we are doing is we are actively lifting the lid and discussing openly for the first time ever some really complex issues. [in order to “lift the lid” and change the organisation one has to understand the problem. Dominic Morgan has consistently shown to staff and the Inquiry Committee that he lacks the insight required. Staff continue to be blackmailed into signing non-disclosure agreements before getting the help they are entitled to, to protect the organisation from external scrutiny]. I've commissioned a random check of stations around New South Wales. This is being directly done out of the Deputy Commissioner's office. HAGAR COHEN: Last year, Ambulance Victoria was under investigation by the corruption watchdog for allegations that 22 paramedics were misappropriating fentanyl and other drugs. In 2014, the Victoria Commissioner personally apologised to 19 people who had wrongly been administered saline instead of fentanyl by ambulance staff. Clive Hawkes served Ambulance Victoria for 37 years. He was team leader at the Haywood station. MICHAEL HAWKES: 37 years' worth, he would have gone to lots of different traumatic cases which builds up and that's, PTSD. That's a big one for him unfortunately. I had no idea that he'd been using fentanyl. HAGAR COHEN: One night in 2015, Clive Hawkes did not return home from work. MICHAEL HAWKES: Mum and I had gone in to the station, saw the ambulance parked out the front and I was the first one that went in and, yeah, I found him slumped in the chair. They didn't resuscitate. They knew it was already past the resuscitation stage and we knew that as well, we knew there was no hope for him unfortunately. HAGAR COHEN: In New South Wales, a specific investigation into fentanyl being switched out for saline is currently under way in the Hunter region. DOMINIC MORGAN: I have commissioned an investigation, a fact-finding investigation, to specifically look into the aspects of fentanyl use and controlled substances within the Hunter area. But I want to be very clear that this is not just focused on Tony Jenkins. [the actions of ANSW in demonising Tony Jenkins and seeking to ruin his reputation are testament to the real mission of any investigation i.e. to make scapegoats of individuals and obviate any responsibility from the organisational culture and management practices]. It is also clear that the “investigation” will be discriminatory and protect certain groups and management within the organisation while vilifying others]. I want to know exactly how these items and controlled substances are being managed within the area, and to make sure that we are following all of the protocols and procedures that we have in place. HAGAR COHEN: If we know that 16 vials of fentanyl have been compromised, potentially patients would have received saline instead of fentanyl. Should the community be concerned about this? DOMINIC MORGAN: It's terribly inappropriate and concerning to me if they were administered saline because that would have meant they had arguably, had inadequate pain relief and that's very distressing for those individuals. What I can say is that there are no reports of adverse patient outcomes at this time. [one of the key issues with ANSW over the years is it fails to ask the right questions. They then assume that they have all the answers. There is no way ANSW will know the answer to this question as there are no measures to identify issues]. HAGAR COHEN: Do you take responsibility though for this situation as New South Wales ambulance ...? DOMINIC MORGAN: Absolutely, at the end of the day, I am the leader of this organisation. [actions speak louder that words. [If this statement was genuine, Sharon Jenkins would not be still fighting for answers and her husband’s reputation]. HAGAR COHEN: So can you assure the community that fentanyl tampering isn't going to happen again? DOMINIC MORGAN: No. Unfortunately, these are one of the real challenges of delivering services which involve highly addictive drugs. [this cannot be promised because this is only a symptom of the real disease. This will be used as a reason to deskill some staff groups, rather than address the actual issues]. And there is no doubt that these drugs can deliver great benefits for our patients and so it's an appropriate part of the paramedic regiment but it comes with a real challenge. HAGAR COHEN: Tony Jenkins' family says the consequences of not looking after the mental health of paramedics puts anyone who calls 000 at risk. SHAYNE CONNELL: We want some answers, we need answers but I think the broader community does, you know, the ambulance service is the organisation that you entrust with care for people when they're in crisis or when there is an emergency. SHARON JENKINS: They know it's a problem. Why are paramedics self-medicating to begin with? [the issue is much bigger than substance abuse, however ANSW does not want to admit the actual root cause, because that means work and bullies losing power]. CIDNEY JENKINS: I think after 28 years of helping everybody else, when it came down to it, he did ask for help and he didn't receive it and he deserved to receive it. [ANSW cannot pretend that it actually cares about staff as an organisation. One individual is considered just collateral damage rather than face the fact that the organisation is fundamentally broken]. KIM JENKINS: It's a recipe for disaster where they go into a job that's stressful and they have that long-term trauma. They are not supported and then they are around these potent dangerous drugs which aren't kept safe from themselves. [Ambulance NSW believes that it has once again escaped real public scrutiny and accountability. Pie-crust promises and crocodile tear apologies will never change culture. Parliamentary Inquires obviously lack the teeth to protect staff from the bullying and abuse at the hands of management in ANSW. The only path that will “lift the lid” on the organisation and expose the rotten core, is a Royal Commission]. |
OCTOBER 9 2018 - 9:30AM - Newcastle Herald
Sharon Jenkins has vowed to protest until NSW Ambulance apologises for implying her late husband had a drug problem
Local News
Protest: Sharon Jenkins stands outside Hamilton ambulance station on Tuesday to protest for an apology after NSW Ambulance inferred her late husband Tony had a drug addiction. Picture: Marina Neil.THE widow of Lake Macquarie paramedic Tony Jenkins has expressed disappointment after a protest outside Hamilton ambulance station today, on the six-month anniversary of her husband’s suicide, while seeking an apology over NSW Ambulance inferring his death was linked to a drug addiction. Sharon Jenkins said public comment by NSW Ambulance chief executive Dominic Morgan after her husband’s death on April 9, and some of the contents of a NSW investigation report, exacerbated the anguish his family felt.
In an ABC interview in May Mr Morgan said of Mr Jenkins: “He was this well-respected, well-regarded professional and it concerns me greatly that a person with that reputation could find themselves so desperate that their only option was to turn to drugs and addiction.”
A NSW Ambulance internal investigation report given to the Jenkins family in September cited reports of Mr Jenkins “appearing sleepy, a series of near miss accidents whilst driving and clinical records not completed to his usual standard” in the months before his death to justify a conclusion that “these behaviours were early warning signs of a possible addiction to Fentanyl”.
The Jenkins family has demanded an apology from NSW Ambulance after the internal investigation report showed a secret review three months before Mr Jenkins’ death concluded there was “no evidence” he “mis-used” restricted NSW Ambulance medications.
“I’m going to stand outside the ambulance station until they apologise,” Mrs Jenkins said before her protest.
“It’s six months on Tuesday since Tony died and the more we learn about events leading up to that day, and on that day, the more questions we have to ask,” she said.
Questions: Lake Macquarie paramedic Tony Jenkins before his suicide on April 9 after a meeting with senior ambulance management. His family is demanding an apology after public statements implied Mr Jenkins had a drug addiction. The family is even more determined for an independent coronial inquiry after a NSW Ambulance internal investigation provided no solid proof to back public allegations 38 Fentanyl vials at four Hunter ambulance stations were tampered with, or that Mr Jenkins was responsible. Fentanyl is a synthetic opioid painkiller 100 times more potent than morphine. Mrs Jenkins also challenged Health Minister Brad Hazzard about the independence of a NSW Health review that will run concurrently with a NSW Police investigation for the NSW Coroner’s office. “We’ve asked for an independent agency to run the review,” Mrs Jenkins said. “Tony is not here to defend himself, but his family is, and we’re determined to continue the fight for answers.”
Mr Jenkins took his own life about two hours after he was dropped off, alone, by a senior NSW Ambulance officer after a meeting where it is alleged he was spoken to about his alleged use of Fentanyl taken from Hunter ambulance stations. NSW Ambulance did not respond to detailed questions last week about the call for an apology and the evidence relied on by the service to suggest Mr Jenkins was addicted to Fentanyl in the period before his death.
In a statement NSW Ambulance said it could not comment because “the circumstances surrounding Mr Jenkins’ death are currently being investigated by NSW Police on behalf of the Coroner”. “NSW Ambulance continues to offer support to the Jenkins family during this difficult time,” the statement said.
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Sharon Jenkins has vowed to protest until NSW Ambulance apologises for implying her late husband had a drug problem
Local News
Protest: Sharon Jenkins stands outside Hamilton ambulance station on Tuesday to protest for an apology after NSW Ambulance inferred her late husband Tony had a drug addiction. Picture: Marina Neil.THE widow of Lake Macquarie paramedic Tony Jenkins has expressed disappointment after a protest outside Hamilton ambulance station today, on the six-month anniversary of her husband’s suicide, while seeking an apology over NSW Ambulance inferring his death was linked to a drug addiction. Sharon Jenkins said public comment by NSW Ambulance chief executive Dominic Morgan after her husband’s death on April 9, and some of the contents of a NSW investigation report, exacerbated the anguish his family felt.
In an ABC interview in May Mr Morgan said of Mr Jenkins: “He was this well-respected, well-regarded professional and it concerns me greatly that a person with that reputation could find themselves so desperate that their only option was to turn to drugs and addiction.”
A NSW Ambulance internal investigation report given to the Jenkins family in September cited reports of Mr Jenkins “appearing sleepy, a series of near miss accidents whilst driving and clinical records not completed to his usual standard” in the months before his death to justify a conclusion that “these behaviours were early warning signs of a possible addiction to Fentanyl”.
The Jenkins family has demanded an apology from NSW Ambulance after the internal investigation report showed a secret review three months before Mr Jenkins’ death concluded there was “no evidence” he “mis-used” restricted NSW Ambulance medications.
“I’m going to stand outside the ambulance station until they apologise,” Mrs Jenkins said before her protest.
“It’s six months on Tuesday since Tony died and the more we learn about events leading up to that day, and on that day, the more questions we have to ask,” she said.
Questions: Lake Macquarie paramedic Tony Jenkins before his suicide on April 9 after a meeting with senior ambulance management. His family is demanding an apology after public statements implied Mr Jenkins had a drug addiction. The family is even more determined for an independent coronial inquiry after a NSW Ambulance internal investigation provided no solid proof to back public allegations 38 Fentanyl vials at four Hunter ambulance stations were tampered with, or that Mr Jenkins was responsible. Fentanyl is a synthetic opioid painkiller 100 times more potent than morphine. Mrs Jenkins also challenged Health Minister Brad Hazzard about the independence of a NSW Health review that will run concurrently with a NSW Police investigation for the NSW Coroner’s office. “We’ve asked for an independent agency to run the review,” Mrs Jenkins said. “Tony is not here to defend himself, but his family is, and we’re determined to continue the fight for answers.”
Mr Jenkins took his own life about two hours after he was dropped off, alone, by a senior NSW Ambulance officer after a meeting where it is alleged he was spoken to about his alleged use of Fentanyl taken from Hunter ambulance stations. NSW Ambulance did not respond to detailed questions last week about the call for an apology and the evidence relied on by the service to suggest Mr Jenkins was addicted to Fentanyl in the period before his death.
In a statement NSW Ambulance said it could not comment because “the circumstances surrounding Mr Jenkins’ death are currently being investigated by NSW Police on behalf of the Coroner”. “NSW Ambulance continues to offer support to the Jenkins family during this difficult time,” the statement said.
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WIDOW DEMANDS CLEARER RESPONSE TO DRUG USE ALLEGATIONS - NBN NEWS 13TH OCTOBER
CLICK ON THE PICTURE TO SEE THE NEWS STORY.
The widow of a Lake Macquarie paramedic is continuing her fight for answers from New South Wales Ambulance.
NSW Ambulance caught lying again to protect its reputation by trying to destroy the character and reputation on Tony Jenkins.
Click on the picture to read the story
Sharon Jenkins questions on ABC Radio the ability of NSW Ambulance to tell the truth in regard to her husbands death and they change key evidence that suggested Tony Jenkins was a drug addict and intent on suicide prior to the fateful meeting with senior managers. . She believes he was used as a scapegoat for a much larger organisational problem.
Read an analysis of the responses given by Government to the recommendations of the Parliamentary Inquiry into bullying, harassment and discrimination; what they said, what they meant and where they failed again to address the issues. Click on the button below to read...
The Senate Inquiry into the Mental Health of First Responders was shown two graphs that very clearly demonstrated the issue of mental health (particularly PTSD) in Ambulance Services in Australia.
In Figure 2.4, 2010-2011 Police (particularly, and to a lesser extent Fire Services) changed the direction of the trend in serious Worker's Compensation claims for mental disorders; while Ambulance has done nothing.
The second graph (Figure 2.5) is a little deceptive by way of its use of definitions and it also hides the poor performing Ambulance Services, like NSW. The reported low rates (compared with the general population) of mental disorders, and their causes, in first responders is contradicted by other research in this area. The suggestion that first responders are only 1/3 as likely to have mental disorders (that the general population) caused from bullying and harassment in the workplace or that exposure to one event leads to serious mental disorders even contradicts the other finding of the Senate Inquiry and evidence from expert witnesses. This graph (and the incorrect assumptions and data made in the graphs) may explain why SafeWork Australia and SafeWork in each state has failed to prosecute Ambulance Authorities for breaches of "duty of care" i.e. because they do not understand the issues nor do they have data that reflects the actual situation.