This report details the findings and recommendations of an investigation undertaken into the quality of care provided to Mr Stewart Kelly, a consumer with neurodevelopmental disorders, during his two admissions to Robina Hospital.

The investigation examined the circumstances surrounding the care and treatment of Mr Stewart Kelly and identified systemic areas of improvement in service delivery.

This report acknowledges the service improvement actions undertaken by Gold Coast Hospital and Health Service since Mr Kelly’s death, which are outlined in the report on page 88.

It is important to note that this report is focused on identifying health service issues and making recommendations to improve systems and processes used to deliver health services.

Read the full investigation report (PDF 1MB)