The
Public Advocate
Influencing change to transform lives
3 June 2020
Mr Graeme Head AO
Commissioner
PO Box 210
Penrith NSW 2750
Via email:
Dear~ ~
The death of ND{(s participant Ms Ann Marie Smith in Adelaide, South Australia
I am writing to you in relation to Ann Marie Smith, who I understand from media reports was an NDIS participant and whose death resulted from long-term neglect by her disability worker and service provider.
As you know, my predecessor in this role released a report in 2016; Upholding the right to life and health: A review of the deaths in care of people with disability in Queensland. The review investigated the deaths of 73 people with disability in care in the period between 2009 and 2014, finding that more than half of the deaths were unexpected and potentially avoidable.
The review called for a wide range of measures to be adopted to prevent the deaths of people with disability in care. This included training for medical and health professionals and disability support workers about the health needs of people with disability; the recognition of the needs of people with disability and complex health needs in their NDIS plans; and improved coordination, integration and communication between mainstream health services, registered NDIS service providers, and other disability support services.
Although the full details are not available, aspects of Ms Smith’s death highlight the need for the NDIS safeguarding system to have ‘flags’ for risk incorporated into the safeguards and protections employed across the NDIS. This is particularly necessary for participants like Ms Smith, who were particularly vulnerable and were receiving a high level of disability support due to her disability and health related conditions.
At present, the NDIS Quality and Safeguards Commission requires service providers to report deaths of participants to the Commission and other serious incidents, including the alleged abuse and neglect of participants, including physical, verbal, and financial abuse. It also requires NDIS service providers to have an incident management system that includes procedures for identifying, assessing, recording, managing, resolving, and reporting incidents. This system is very comprehensive and will ultimately result in the recording of a great deal of relevant information . that will assist to safeguard people with disability who are receiving NDIS supports.
However, the incident management system did not protect Ms Smith from the neglect that took her life. The system identified no flags for risk that might have triggered an intervention that could have saved Ms Smith’s life. For people like Ms Smith, who are particularly vulnerable, in terms of Level 7, 50 Ann Street, Brisbane I GPO Box 149, Brisbane QLD 4001 I 07 3738 951 3 I public.advocate@justice.qld.gov.au I publicadvocate.qld.gov.au
their disability and dependence on others for care, and who have few family or community supports, there is clearly a gap in the NDIS reporting systems, in terms of monitoring the health and wellbeing of this particularly vulnerable cohort. Her case highlights the need for the auditing and monitoring processes within the NDIS to provide for monitoring of the health and wellbeing of participants, perhaps through quarterly, independent ‘health and wellbeing’ checks as a component of the regulatory and registration system, including requiring service providers to undertake, at least annual, reviews of the skills and standard of support provided by their workers/employees to NDIS participants through observing them at their work.
Ideally, participants would not receive services from just one worker for an extended period instead, workers should be assigned on a rostered basis, which could allow for peer monitoring.
I understand that people with disability often develop quite close relationships with their support workers and may want to use their services exclusively. While in many cases, this can be a positive outcome for the person with disability, it needs to be balanced with appropriate safeguards and monitoring to minimise the risk of neglect or abuse that might go undetected, as appears to have occurred in Ms Smith’s case.
As recommended in response to the ‘Right to life and health’ report, if the NDIS had been monitoring whether Ms Smith had seen a doctor (even a GP) in the last 12 months of her life, problems with the neglect of her support worker may have been detected. It is not acceptable when the NDIS funds the level of personal care for a participant, that it seems Ms Smith required, that it takes no active interest in the health needs of the person who is obviously extremely vulnerable and dependent on her disability workers for all of her care and support needs.
More stringent accountability processes are particularly necessary to ensure quality of care and safeguards for people with disability who have no, or limited, networks of support that would otherwise provide a level of oversight of their care. Introducing a community visitor program similar to that operated by the Public Guardian in Queensland, might be one option to provide a system of ‘eyes on the person’ oversight for NDIS participants like Ms Smith who have limited networks of support. An alternative might be for the NDIS to introduce a program for advocacy support as part of the funding for this cohort of participants where the advocacy service is expected to visit the person on a regular basis. This provides a level of oversight of the person, their care and wellbeing, that is independent of the participant’s disability service provision.
Having systems for independent monitoring of the health and safety of NDIS can only lead to better health and wellbeing outcomes for participants. ·
I would be very pleased to engage with your office to discuss the suggestions I have made and any other assistance I can provide to support the NDIS Quality and Safeguards Commission to implement appropriate monitoring and reporting to respond to this sad incident and ensure people with disability receive the care they need to live their most productive and satisfying lives.
If you wish to further discuss these issues, please do not hesitate to contact me at my office on 1 or via email
Yours sin9erely
Mary Burgess( /
Public Advocate-(-Queensland)
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