Richard Hendrie is a man with a big presence, whose vocabulary reflects his years immersed in textbooks.
Speaking about mental illness, his opinion is steadfast and delivered with unbroken eye contact.
But there can be times when this assuredness is void. In an acute, dissociative state, Mr Hendrie can become non-verbal and lose consciousness of what is around him.
The 31-year-old from Henty was heavily dissociating in March of last year when his mother, Susan Maher, took him to the Albury emergency department.
"I was there for 24 hours and placed under the Mental Health Act," Mr Hendrie said.
"My only clinical support was a security guard.
"I was then transferred to the Kerferd Unit because Nolan House was at capacity.
"I was there for about five days, and then I was supposed to go down to a PTSD clinic in Melbourne."
A transfer to the clinic was organised by the Department of Veterans' Affairs, but when the day came, arrangements had fallen through.
DVA instead organised for a private taxi to take Mr Hendrie to Melbourne.
Despite admission notes requesting only female staff work with Mr Hendrie, the 31-year-old was put in the taxi with a male driver.
Once they had left, Mr Hendrie's mother, who is also his guardian, was called.
She immediately expressed concern - and she was right to be worried.
"When I got down to the PTSD clinic, I disassociated heavily because I'd been on high alert the entire time, and the nursing unit manager there was furious I had been sent down in a taxi," Mr Hendrie said.
"When the senior executive at AWH were notified of that, they didn't have the courtesy to respond."
Mr Hendrie's mother wrote to the Mental Health Complaints Commissioner that staff did not use trauma-informed care, her son was negatively affected by the experience and she had made a complaint to AWH on April 8 but did not receive a response until May 28.
AWH chief executive Michael Kalimnios apologised for that delay in his response to the Commissioner.
He said that Mr Hendrie was accepting of the driver and there were three phone calls made by staff en route to Melbourne which did not indicate distress on Mr Hendrie's behalf.
The Health Complaints Commissioner is investigating the incident further, Mr Hendrie has been told.
"I remember actually having a conversation with the then-chair of Albury Wodonga Health, about a month before I got admitted to Kerferd, saying that I know that if I present to Albury ED, I won't get proper health care," Mr Hendrie said.
"One month later, they didn't fail to disappoint.
"When DVA arranged a taxi, they did so on the medical advice at Kerferd, who deemed it appropriate.
"I had come straight from one-to-one care under the Mental Health Act to being clinically OK to travel with a taxi driver as my clinical support in a hospital-to-hospital transfer - I wasn't being discharged.
"No one at Kerferd had the clinical insight to prevent this from happening."
Even spending time in the emergency department can be inherently damaging for people who are in mental distress.
The Victorian Royal Commission into Mental Health stated "waiting long periods in high-stimulus emergency department environments, often for little therapeutic contact, can exacerbate mental health crises".
The report found the majority of those who stay longest in Victorian emergency departments were mental health patients.
In 2019-20, people experiencing mental illness or psychological distress comprised 63 per cent of all 24-hour breaches.
All health services aim to have no patients stay greater than 24 hours, but in Albury hospital last year, there were 273 people who stayed in ED longer than 24 hours. At Wodonga, there were 55 people.
These instances of care and whether they are mental-health-related are not detailed for confidentiality reasons.
Albury Wodonga Health mental health executive director Lucie Shanahan said the service was deeply sorry for the distress experienced by Mr Hendrie.
"We have taken direct measures to improve practice in response," she said.
"Significant changes have occurred across the AWH Mental Health Service in the last year, and specifically in the inpatient units.
"We continue to be grateful to Mr Hendrie for drawing our attention to his experience and advocating for change on behalf of others, with a desire to improve the system for all."
Improvements have included the development of an inpatient mental health model of care "which is proving to substantially reduce restrictive interventions", the introduction of therapeutic group programs and implementation of therapeutic engagement guidelines.
The introduction of an Acute Community Intervention Service has provided 24/7 local specialist mental health triage and since July last year, Ms Shanahan said.
"This service has dramatically reduced 24 hour breaches and has made mental health care available on-site in the emergency department," she said.
"These reductions were achieved during the height of the COVID pandemic when mental health demand doubled."
Ms Shanahan said Albury Wodonga Health welcomed the findings and recommendations of the Royal Commission into Victoria's Mental Health System.
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"The recommendations are underpinned by a set of guiding principles that align with the cultural change Mr Hendrie, and many others, including those who work in the system, would like to see," she said.
"Investment in workforce, new and innovative service models, and having people with lived experience leading the design and delivery of services will all work to provide people with the care they need, in a way they need, in the location they need.