article_snippet.sent: Coroner Mark Johns' said nothing short of a 'massive overhaul' was required by the agency. '
article_snippet.sent: Handing down 22 recommendations to improve the system, Mr Johns said there had been a lack of analysis, lack of clinical supervision and a lack of leadership.
highlights_snippet.sent: Their interactions involved a 'history of drift, irresolution and aimlessness'
  Coroner recommended 22 changes to the government .
  