"It was a physical sexual assault, yet no police were called, and I wasn't notified until 9 or 10 the next morning," Ms Field recalls. "She was hysterical. From that moment on, there was no reprieve. Her suicidality and mental health spiralled out of control. The very place that was supposed to keep her safe failed her on so many levels." Years since this incident, St Vincent's says it has modified its acute unit to include gender-specific areas and locks on doors, and consistently reviews its practises to ensure patients are safer. But the tragedy is emblematic of a broader problem in mental health which, according to patients and and those who work within the system, appears to be getting worse. Unacceptable risks and cover ups

Fairfax Media can reveal that vulnerable people seeking psychiatric treatment in state-run hospitals continue to face unacceptable rates of sexual assault and violence, mostly from other patients, amid accusations that some staff are trying to cover up the extent of the problem. Insiders, speaking on the condition of anonymity, have accused managers of failing to log information properly, of doctoring and downplaying reports, or of not immediately alerting police. And Victoria's chief psychiatrist, in a rare public interview, has conceded that the number of serious incidents that land on his desk continues to rise, with a fresh review of guidelines now under way into how allegations of sexual assault should be managed. "I've certainly got more reports," Dr Neil Coventry told Fairfax Media. "Whether that means there's actually been more instances, or that there's a stronger cultural awareness around reporting, I can't say. But my view is that one assault is too many. Every story has a tragedy behind it." The tragedy here is that the issue of sexual safety in the mental health system is not new, yet years of appalling abuses have failed to force the kind of sweeping reform that is needed.

Indeed, alarm bells were ringing years ago, when a 2013 survey by the Victorian Mental Illness Awareness Council found that 45 per cent of women treated in psychiatric hospitals had been sexually assaulted in state care. The study found more than two-thirds – 67 per cent – had been sexually harassed and 85 per cent reported feeling unsafe. Fairfax Media has spoken to patients and carers, mental health lawyers, researchers in the field, and state watchdogs – and all fear that too many patients are still being put at risk. "The situation hasn't changed; if anything, I'd have to say we're worse off," says Professor Jayashri Kulkarni, the director of the Monash Alfred Psychiatry Research Centre, who has spent decades researching women's mental health and is advocating for single-sex wards. "It's disgraceful." 'It's disgraceful': Professor Jayashri Kulkarni, Director of Monash Alfred Psychiatry Research centre.

While the department has refused to release figures showing the scale of sexual assaults – or indeed, any critical incident reports from the mental health system – an analysis of publicly available data paints a troubling picture. Statistics from Public Advocate Colleen Pearce, for instance, show that Community Visitors – the independent volunteers who visit psychiatric patients as part of unannounced spot-checks – have recorded rising sexual assault and violence allegations every year, from 27 in 2011-12 to 101 last year. "(That) is dangerous by any standards," Ms Pearce says. The Mental Health Complaints Commissioner received 1638 complaints last financial year covering a broad range of matters - 249 more complaints than the year before. The office won't say how many relate to sexual allegations, but the issue sparked enough concern in the past 12 months that it recently commissioned Professor Kulkarni to help with an inquiry into sexual safety in mental health wards. Whether it paves the way for much needed change is yet to be seen. Part of the problem, after all, is cultural: the tendency for women with severe mental disorders to be viewed as "too unreliable" when they make complaints; the inability of some staff to recognise inappropriate behaviour; and an expectation by some that sexual activity in psychiatric wards is unavoidable because acute, drugged-up patients can be "disinhibited" and highly sexualised.

But part of it, too, is that basic protocols simply aren't being followed. As many have pointed out: if this happened in general hospitals, there would likely be a public outcry. Last November, when a woman was allegedly sexually assaulted by a male patient in a seclusion unit of Barwon Health's Swanston Centre, it didn't take long for the chief psychiatrist to discover a litany of "serious deficiencies" in the way seclusion areas had long been used. It was an accident waiting to happen: little oversight by staff and too much risk for patients. Public Advocate Colleen Pearce. Concealing a crisis Or take St Vincent's Hospital, when Julie Preston was physically assaulted in the weeks before she was raped. Her carer, Karen Field says she'll never forget arriving at the ward one afternoon to find Julie with a black eye. Yet, it took another two attacks before a male patient was finally removed, she says.

"We know that most women who end up in the mental health system have a history of childhood or sexual abuse, or in some cases both, so you're often dealing with exceedingly high-risk, traumatised individuals," says Ms Field, who now works in social services. "Julie was supposed to be in their care, but it felt like we were on a hiding to nothing." The lack of transparency in reporting has also led to fears that some managers are trying to conceal a growing crisis. Insiders have told Fairfax Media of cases where serious assaults have been downplayed by hospital staff, or of incident reports either being heavily redacted, delayed, or not provided at all. In the push to drive change, some of these concerns have even been documented in annual reports tabled in parliament. After the Barwon Health assault last year, for instance, it took Community Visitors from the Public Advocate's office five months to receive an incident report, despite a departmental code of practice reinforcing their right to view such information. Closer to town, at the Banksia Ward of the Royal Children's Hospital, Community Visitors recently waited an hour to view incident reports that ultimately were not provided. This was despite an agreed protocol in place that was prompted by an earlier assault. In that case, a male teenager was bashed after he refused to perform a sex act on another male patient. Both were in a high dependency unit at the time, with no staff present. As one insider told Fairfax Media: "If you don't know what's going on you can't monitor the situation, and you can't make improvements."

Ice, crowding and a lack of staff So why has it come to this, and what is the solution when the mental health system is a such a complex beast with finite resources? Victoria has 39 acute inpatient units, delivered through 18 designated hospital services, from Eastern Health and Monash Health in metropolitan Melbourne, to Albury Wodonga Health or the New Mildura Base Hospital in regional Victoria. The trouble is, beds and staff are so thinly spread that in order to cope with demand, hospitals have reduced a patients' length of stay and increased the threshold at which they can be admitted to a ward. As a result, the average mental health patient is sicker both on admission and on discharge than they were five years ago. Add to this a chronic lack of funding, the proliferation of ice, and the design of inpatient units – most of which are mixed-sex environments in which male patients tend to outnumber females – and it's not hard to see why the system is under so much strain.

A number of improvements have been made in recent years: gender-sensitive training here; a women's-only lounge there. But most agree there's much more to do. Some, like Health and Community Services Union official Paul Healey are pushing for more staff, with the union claiming there are about 350 state-wide vacancies. Others, like Professor Kulkarni, believe that one way to improve safety is to establish single-sex units, which is how psychiatric wards operated in Victoria until the 1960s. Such a shift took place in the UK in 2006, when the government adopted a strict policy of gender segregation following escalating assaults in inpatient units. Others, however, are not convinced that women's-only wards are the answer. Consensual sex? "One of my concerns is that people had a very black and white view that we're only talking about vulnerable women being preyed on by aggressive males. Yes that happens, but this cuts across all ages and all genders, including people in the LGBTI community," says chief psychiatrist Neil Coventry.

"My view personally, is that units need to be safe for everybody coming in." Coventry cites a range of measures that could be applied instead: more secure rooms with swipe-card-only access; improved staff-to-patient ratios; better risk assessment when patients are admitted and staff are well aware of their history and trauma "triggers". He's also conducting a review of safety guidelines to ensure that staff properly report alleged incidents, admitting that in the past, such disclosures have been "patchy." The new guidelines will encourage hospitals to be more open with families "so there's no sense of a cover-up" and will emphasise the need to fully consider the long term effects of trauma when treating patients. Importantly, they will also seek to clarify an issue that causes ongoing confusion among some staff: that consensual sex between psychiatric patients is appropriate. Put simply, says Coventry, it's not and never can be. "People who come into psychiatric units are very unwell. One must assume they don't have capacity to be making decisions like that, so there's no point thinking about consensual versus non-consensual," he says.

It's a complex problem, the chief psychiatrist admits, and the answers aren't easy. "I think we're getting there, but I think we have quite a way to go, to be honest." Do you know more? Contact: ftomazin@fairfaxmedia.com.au