The Commission of Inquiry into the Townsville General Hospital Psychiatric Unit, Ward 10B, was established under the provisions of the "Commissions of Inquiry Act 1950" by Order in Council 31 May 1990.
Under the terms of reference, the Commission was to investigate "whether during the period 2nd March, 1975 to 20th February, 1988 any patient in the Townsville General Hospital Psychiatric Unit (Ward 10B) was cared for or treated by any member of the staff of that hospital or any other person permitted, suffered, engaged, or authorised (whether contractually or otherwise) by any member of the Board or staff of that hospital or any person employed in the Department of Health to have the care or treatment of such patient or any other person involved in the care or treatment of any such patient, in a manner which was negligent, unsafe, unethical or unlawfull". The Commission was also to establish "whether there is sufficient evidence to:...prosecute or take disciplinary proceedings against any person..."
The Commission was to create a report within six months and submit it to the Minister for Health. Mr Justice William Joseph Carter headed the report and Graeme Allan Forbes was secretary.
CONDUCT OF THE INQUIRY:
The Commission, through its investigative process, identified that the deaths of some patients required close investigation and, in some cases, it should be considered whether the "negligence was of such a degree as to provide evidence of criminal negligence". Carter recommended a review of the Mental Health Services Act and he called for consideration to be given to outlawing some aspects of the "therapeutic community" model of psychiatry, as practiced in Townsville from 1975 to 1987.
The report of the Inquiry was tabled in Parliament on 26 February 1991. It consisted of two volumes, titled "Commission of Inquiry into the care and treatment of patients in the Psychiatric Unit of the Townsville General Hospital between 2nd March, 1975 and 20th February, 1988 - Report - Vol I: Summary of Findings, Recommendations and Commissioner's Report - February, 1991" , and ..."Vol II: Appendices A, B and C - February, 1991" (these volumes can be found in items 1515067 and 1515068 of series 19428).
A supplementary report issued by Carter, which outlined offenses he found sufficient evidence to prosecute or take disciplinary action upon, was not released at the time.