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LISA... is a parent support and lobby group, for parents and families with a family member having an intellectual or multiple disability, and living in a supported accommodation group home in the State of Victoria, Australia.
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JacksonRyan Partners

Neglect – Abuse - Violence - Death

Living in Victoria’s disability accommodation sector is a game of chance

If you are one of the 5,000 or so people with a disability living in one of Victoria’s disability supported accommodation homes, then it is a game of chance whether your life will be good or whether you will be subjected to neglect, abuse, violence or even death.

The recently released Community Visitor Board 2014 Report Annual report expresses "real concerns that abuse and neglect of people with disabilities, including neglect of healthcare, is systemic in group homes."  Community Visitors are a highly respected body of people who operate under the authority of the Disability Act 2006.  Included among their eight functional legislative authorities is one that requires them to “inquire into any case of suspected abuse or neglect” of a person living in a supported accommodation house.

The Board report highlights that abuse and neglect is physical, sexual and emotional.  It calls on the State Government to focus "on crucial measures needed to address the abuse and neglect of people with a disability". Further, for the establishment of "a formal independent inquiry into abuse and neglect in group homes.”  It must be assumed that the Community Visitors Board’s call has only been made after careful consideration of the implications of such a significant recommendation.

The report also highlights that there are vulnerable people living in a support service called Plenty Residential Services (PRS) where some people are being put at risk by the introduction of new residents who exhibit what are called behaviours of concern, with some having been involved in the criminal justice system. 

There is reference in the report to what are known as incident reports.  These reports are an internal reporting system through which funded service providers, as well as services managed by the Department of Human Services, are required to report particular types of incidents against a system defined by Category One, Category Two and Category Three incidents.

The Community Visitors Board expressed concern that incident reporting, "has been inaccurate and lacked transparency".  The report further states that, "the efficacy of incident reporting" is questionable on the basis that if incidents are not reported, or poorly reported, then any necessary remedial action is likely to be ineffective.  The report’s inference is that the level of abuse and neglect is much greater than that which is reported through the incident reporting system. 

The significance of incident reports also features in a report entitled, Beyond Doubt – The experiences of people with disabilities reporting crime – Research findings, which was released by the Victorian Equal Opportunity and Human Rights Commission in July 2014.   The concerns reported by community visitor regarding the efficacy of many incidents reports is also reflected in the Beyond Doubt report where it is stated that while, "client–to-staff violence would be reported as a crime while categorisation of client–to–client violence was skewed towards not being reported to police."  The report further notes that despite there being policies and guidelines requiring such incidents to be reported to the police that the "practice on the ground varied."  The DHS website has the latest figures for 2014.

Figures from these two sources are reproduced in the table below.  It is notable that the figures as recorded are significant and it is important to understand why there appears to be a significant drop in the number of deaths in the 2012–2013 and 2013-14 years compared with the three previous reporting years.  It would be wrong to automatically assume that there had been a significant drop in the number of deaths.  It is crucial to understand that late in 2011 the Minister responsible for the Department of Human Services made a change to the reporting of deaths through the incident reporting system.  The crucial change was that all deaths were no longer reported as Category One incidents and instead some were recorded as Category Two incidents.  As the Department of Human Services does not release figures for Category Two incidents, this accounts for the illusion of a reduction in the number of resident deaths. 

Number of Category One critical incidents by incident type in Disability Services

Category one incidents
























Other Incident types






It is worth repeating that the change invoked in late 2011 meant that not all deaths that occurred in disability supported accommodation houses would continue to be reported as Category One incidents.  A significant feature of the change was the decision that only those deaths considered to be "unexpected and unexplained" should be reported as Category One incidents.  This therefore meant that all other deaths would be recorded and reported as Category Two incidents. 

Of equal significance is the fact the Department of Human Services does not make available the Category Two incident numbers.  This therefore means that a significant number of deaths that are occurring in the supported accommodation sector are not made public.  In effect they are hidden from the public’s view.  This is totally contrary to the call as made in the Community Visitors report that “accurate, open and comprehensive incident reporting is integral to elimination abuse and neglect.”

Given Category One deaths are defined as “unexpected and unexplained” the logical conclusion must therefore be that Category Two deaths are “expected and explainable”.  Yet, by hiding the Category Two death numbers, how can such a determination be made given that at the time the incident report is written given this occurs before any investigation has been undertaken or before the Coroner has considered each particular death.  Could it be that by in effect hiding the Category Two number of deaths the Department of Human Services is seeking to create the impression that death in care is not a significant issue?  Or can it be concluded that perhaps there is something to hide?

While it is not possible to be definitive in terms of the total number of deaths that have occurred in supported accommodation facilities since January 2012, noting again that those deaths reported as Category Two incidents are hidden from public scrutiny, it is, nonetheless, possible to make a reasonable extrapolation from the death figures provided for the two reporting years 2009–2010 and 2010–2011.  Certainly, it seems reasonable to suggest that there is likely to have been somewhere between 200 and in excess of 270 deaths per year.  If this figure is reasonably accurate then this equates to the least four, and upwards of five or six deaths per week across the disability accommodation sector.  However else this figure is considered it is must be considered as high.  After all, disability accommodation can in no way be equated to aged or palliative care facilities.

When the death figures are considered in concert with the matter of abuse and neglect as expressed in the Community Visitors Board report, this must resonate as a significant concern that can no longer be ignored.

Although the current Victorian State government and the Federal government have initiated significant actions in relation to the abuse of children in care, and particularly alleged sexual abuse, the same level of investigative clout has been missing in relation to allegations of abuse, including sexual abuse, neglect, violence and death in the disability accommodation sector.

It is not an overstatement to suggest that sexual abuse does exist in the disability accommodation sector.  Two staff, previously employed by the Yooralla organisation, were recently found guilty of the rape of clients in Yooralla managed accommodation services.  A third case involving a Yooralla staff member is due to come before the court in late October this year.

The evidence that supports the claim that abuse, neglect, violence and deaths are occurring in disability supported accommodation facilities must be heeded.  It would be too easy to suggest that the nature of people with disabilities is such that they are automatically prone to exhibiting extreme challenging behaviours.  It would be too easy to suggest that the health of people with disabilities in care is such that the majority of deaths might be expected and explained.  And, it would be too easy to suggest that child protection and the actions of investigating the abuse of children should necessarily have a higher priority than that of establishing an inquiry into the neglect, abuse, violence and deaths occurring in residential facilities for people with disabilities.

The State of Victoria has an Ombudsman, a Public Advocate, Community Visitors, a Disability Services Commissioner, a Senior Practitioner, a myriad of funded advocacy organisations, strong legislative provisions and funding contracts between the Department of Human Services and funded disability service organisations.  Yet, despite these so-called protective mechanisms, neglect, abuse, violence and deaths continue unabated.  

It is now time to end the farce of pretending that the disability sector is truly concerned about the rights and protection of people with disability.  It is now time for the government to act.  It is also now time for those entities that are paid to protect the rights and wellbeing of people with disabilities in residential facilities to stand up and be counted and do their job.

If the call by the Community Visitors Board for an inquiry into the abuse and neglect in disability accommodation services is ignored then who will take responsibility for addressing this social scandal?  Where will people with disabilities, their families and those concerned about the protection and rights of people with disabilities turn?

Although an inquiry should have been initiated well before this, given the evidence concerning neglect, abuse, violence and the death of people with disabilities in residential facilities, the time for an inquiry must be now.

Max Jackson & Margaret Ryan

JacksonRyan Partners                                                                          1 October 2014

Contact Max Jackson on 0413 040 654 and Margaret Ryan on 0412 409 610

LISA Inc   ~   Phone: 03 9434 3810   ~   Email:   ~   Address: 73 Nepean Street Watsonia VIC 3087

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