Chapter 5
Reporting and investigating
5.1
This chapter addresses the following terms of reference:
(d) the responses to violence, abuse and neglect against
people with disability, as well as to whistleblowers, by every organisational
level of institutions and residential settings, including governance, risk
management and reporting practices;
(e) the different legal, regulatory, policy, governance and
data collection frameworks and practices across the Commonwealth, states and
territories to address and prevent violence, abuse and neglect against people
with disability; and
(h) what should be done to eliminate barriers for responding
to violence, abuse and neglect perpetrated against people with disability in
institutional and residential settings, including addressing failures in, and
barriers to, reporting, investigating and responding to allegations and incidents
of violence and abuse.
5.2
This chapter examines the efficacy of reporting and investigating mechanisms
for allegations and incidents of violence, abuse and neglect, including:
-
internal reporting mechanisms by disability support
organisations; and
-
external reporting mechanisms to independent bodies.
5.3
Overwhelmingly, the committee heard that Australia's existing legal and
policy frameworks are inadequate, overly complex and do not provide adequate
protection to people with disability in residential and institutional settings.
A number of submissions highlighted that there are no clear or nationally
consistent mechanisms for reporting abuse, neglect or violence and recommended
the introduction of national, independent reporting mechanisms.[1]
5.4
The inadequacy of the current approach means that there is no accurate
data on the actual level of violence, neglect and abuse being perpetrated on
people with disability.
Reporting allegations of abuse, violence and neglect
International obligations
5.5
Under Article 16 of the United Nations (UN) Convention on the Rights of
Persons with Disabilities (Disability Convention), Australia is obliged to
ensure that people with disability are not subject to any forms of
exploitation, violence or abuse.[2]
5.6
In its concluding observations on Australia's first report on the Disability
Convention, the UN Committee on the Rights of Persons with Disabilities
(UN Disability Committee) expressed particular concern about reports of
high rates of violence against women and girls living in institutional
settings, and recommended an urgent investigation.[3]
5.7
To complement the UN Disability Committee's report, the Australian Human
Rights Commission argued that this inquiry should give consideration to the
2012 Civil Society Report to the United Nations Committee on the Rights of
Persons with Disabilities (Civil Society Report), prepared by Australian
disability support organisations.[4]
The report highlighted that in Australia:
...there is no specific legal, administrative or policy
framework for the protection, investigation and prosecution of exploitation,
violence and abuse of people with disability.[5]
5.8
In regard to Article 16 of the Disability Convention, the Civil Society
Report recommended that Australia should establish 'an independent, statutory,
national protection mechanism that has broad functions and powers to protect,
investigate and enforce findings related to situations of exploitation' and a 'national
coordinated strategic framework for the prevention of exploitation, violence
and abuse experienced by men, women, girls and boys with disability'.[6]
Internal reporting mechanisms
5.9
For the purposes of this report, internal reporting is defined as the reporting
of incidents within the service provider, and also the reporting of incidents as
required to the government funding body.
5.10
In most jurisdictions, there is a policy requirement for funded
disability service providers to report 'serious' or 'critical' incidents to the
relevant department providing the funding for investigation and response.
Serious or critical incidents are events that threaten the safety of people or
property. A serious or critical incident could be:
-
the death of, or serious injury to, a resident;
-
allegations of, or actual, sexual or physical assault of a
resident; or
-
significant damage to property or serious injury to another
person by a resident.[7]
5.11
Serious incidents may be reported to disability service providers by
people with disability and their families, or by staff and carers. In many
cases, the service provider is responsible for identifying and reporting
incidents, and deciding how the response is to be managed.
5.12
Table 5.1 outlines the different requirements across jurisdictions for
reporting critical or serious incidents.[8]
Table 5.1: Reporting requirements of serious
or critical incidents for funded disability service providers
Jurisdiction
|
Legislative/policy
requirement
|
Responsibility to report
|
Agency to report to
|
NSW
|
Legislation – Ombudsman Act 1974, Part 3C
|
Funded service providers
Department of Families and Communities
|
NSW Ombudsman
|
Victoria
|
Policy – Responding to allegations of physical or sexual assault
|
Funded service providers
|
Department of Health and Human Services
Police
|
Queensland
|
Policy – Critical Incident Reporting Procedures
|
Funded service providers
|
Department of Communities, Child Safety and Disability Services
|
WA
|
Policy – Serious Incident Reporting
|
Funded service providers
|
Disability Services Commission
|
SA
|
Policy – Managing Critical Client Incidents Policy
|
Funded service providers
|
Department for Communities and Social Inclusion
Police
|
Tasmania
|
Policy – Serious Incident Policy / Preventing and Responding to Abuse
in Services Policy
|
Funded service providers
|
Department of Health and Human Services
|
NT
|
Policy – Disability Service Standards
|
No formal requirement to report
Mandatory reporting for children under 18 only
|
Department of Children and Families
Police
|
ACT
|
Regulation – Disability Services Regulation 2014, Section 10
|
Funded specialist disability service providers
|
Director-General, Community Services Directorate
|
Source: Refer to footnote 8.
Efficacy of internal reporting
processes
5.13
As outlined in Table 5.1, in all jurisdictions but New South Wales (NSW),
the process for reporting violence, abuse and neglect is defined by government
disability-related policy. These policies differ across jurisdictions,
including how 'serious' or 'critical' incidents are defined, and how they
should be responded to. Submitters and witnesses highlighted that existing
policies are not effective in ensuring that 'serious' or 'critical' incidents
are adequately reported and investigated.[9]
5.14
Some disability service providers have internal processes to report and
respond to incidents of abuse and neglect. For example, the Endeavour
Foundation submitted that it has implemented strategies to develop a zero
tolerance culture for abuse, neglect and exploitation, including utilising an
External Advisory Committee for the Prevention and Response to Abuse Neglect
and Exploitation and training all staff in human rights and abuse recognition.[10]
5.15
However, evidence to the committee suggested that in many cases,
allegations of serious or critical incidents are not consistently reported. The
Tasmanian Anti‑Discrimination Commissioner submitted that, while service
providers are required to notify the relevant department within two working
days of being notified of an allegation of abuse:
...complaints made to my office would suggest that not all
incidents are reported. Nor is there a clear understanding about the procedures
adopted by residential or other accommodation service providers about the
mechanisms for investigating such complaints.[11]
5.16
Evidence was presented to the inquiry that there is a problem with
funding bodies investigating the organisations they fund, due to the inherent
conflict of interest:
At the moment there is also too much of a conflict in funding
bodies investigating who they are funding. The organisations have too much
invested, and obviously there is often a direct conflict of interest there in
terms of who is independent and who can look at a situation and make a
judgement based on probabilities rather than a criminal threshold as to whether
or not something has occurred, then perhaps being able to compel a support
agency to respond in a more appropriate way.[12]
5.17
This view was echoed by Speaking Up For You. Mr Neal Lakshman, Advocacy
Worker, told the committee:
I guess the issue is that Disability Services is
investigating itself at the moment. We may have a complaint against a DSQ [Disability
Services Queensland] officer, and then six months later he might be in the
complaints unit, so it can be quite difficult.[13]
5.18
Where incidents are reported, there may be differences in the way they
are handled. The Victorian Disability Services Commissioner noted that, since August
2012, it has reviewed 888 'category one' incident reports relating to
allegations of staff-to-client assault and unexplained injury made to the
relevant government department and community service organisations. The reviews
highlighted that there is a 'lack of focus on people's outcomes and
safeguarding people's rights during investigations' and a 'lack of clarity and
shared understanding' of the definition of 'assault' and 'poor quality of care'.[14]
5.19
One suggested cause for the lack of reporting is the perceived 'conflict
of interest' of internal self-reporting. The Australian Cross Disability
Alliance (Disability Alliance), representing national disability support
organisations, suggested that the current system of having funded disability
service providers reporting to funding agencies:
...presents an inherent conflict of interest, and has been
found to be a major problem in the reporting (and non-reporting) of violence
against people with disability in institutional and residential settings. There
is now indisputable evidence to demonstrate that the 'covering up' of
complaints, 'serious/critical' and other 'incidents', is rampant at all levels
of the system—at the direct service delivery level, at management and
governance levels, and at 'funding agency' levels, including large Government
Departments.[15]
5.20
Some submitters suggested that the governance of institutions and
residential facilities did not foster a culture of identifying and reporting
incidents and allegations of abuse. Queensland Advocacy Incorporated suggested:
There are significant problems marring the efficacy of the
governance, risk management and reporting practices of institutions
providing care for people with disability. This flows, to a large degree, from
the predominant culture of institutions, which are traditionally hierarchically
structured, paternalistic and lack transparency and accountability.[16]
5.21
Witnesses suggested some institutions are reluctant to report incidents and
allegations of abuse due to possible negative publicity. Ms Heidi Egarter, a
disability support worker with the Health and Community Services Union, told
the committee of concerns about:
...the tardiness and reluctance to act on allegations of abuse
by non‑government agencies in particular. There appears to be a culture
of suppressing information that could lead to negative publicity. I believe
this is endemic and perpetuated throughout the management structure.[17]
5.22
The committee was particularly concerned by evidence that suggested in
some cases allegations of abuse and neglect are not reported at all and are
dealt with internally by disability service providers. The Disability Alliance
criticised the use of the terms 'serious' and 'critical' incidents to describe
'what is understood and recognised in the broader community as violence, rape,
sexual and physical assault, grievous bodily harm, domestic violence,
gender-based violence etc', noting that this may lead to incidents not being
reported appropriately. Under existing frameworks, these crimes are not
reported to police, but treated as internal service incidents:
The reframing of violence, abuse and neglect, including
crimes are often reframed by terminology such as 'abuse' or 'service incidents'.
This creates a greater potential for such 'incidents' to go undetected,
unreported, and not investigated or prosecuted because they are more likely to
be dealt with administratively within the service setting.[18]
5.23
Evidence presented to the inquiry noted that where allegations were not
followed up appropriately, that can create culture which actually fosters abuse
and neglect:
When abuse is ignored, or when people report abuse and it is
ignored or not properly heeded, that again signals to the person that their
issue is not important to somebody, that they are alone and that this kind of
practice is acceptable, understandable and even common practice.[19]
5.24
The committee notes that the proposed National Disability Insurance
Scheme (NDIS) quality and safeguarding framework consultation paper acknowledged
the 'need to decide how serious incidents will be handled'. The consultation
paper noted that '[i]ncidents involving allegations of assault, theft or any
other crime must of course always be reported to the police'. Possible options
for reporting serious incidents canvassed in the consultation paper included:
-
requiring that all providers have effective internal systems in
place to deal with serious incidents; or
-
requiring that registered providers report serious incidents to
the National Disability Insurance Agency (NDIA) or an independent oversight
body.[20]
Responses to internal
whistleblowers
5.25
The committee is concerned by evidence of negative workplace responses
to whistleblowers who seek to report allegations and incidents of abuse,
violence and neglect. The Disability Alliance submitted:
...the widespread problem of 'whistleblowers' being bullied,
harassed, persecuted, intimidated, deployed to other positions, and sacked,
when reporting (or attempting to report) violence against people with
disability in institutional and residential settings—is yet another serious
dimension in the complaints processes and mechanisms, and remains an un‑addressed,
systemic issue nationwide.[21]
5.26
One submitter expressed concern that:
Many complaints are often ignored or not investigated because
other staff who are witnesses to the abuse are too scared to speak up because
they know whistleblowers are hounded out of the system.[22]
5.27
During its inquiry, the committee heard from whistleblowers about their
experience attempting to report allegations and incidents of violence and abuse
to internal and external bodies (see Box 5.1 and 5.2). The committee notes that
many witnesses asked to provide evidence in camera or as name withheld, citing
concerns about repercussions. The committee believes this is indicative of an
environment that inhibits whistleblowers, and highlights the bravery of those
who spoke out publicly.
Box 5.1:Whistleblowers – Ms Julie Sullivan
For the past 20 years, Ms Julie Sullivan has spoken out against abuse against people with
disability that she witnessed while working at a government run community residential unit for
people with disability in Victoria during the 1980s and 1990s. During this time, Ms Sullivan
witnessed abuse and violence perpetrated by staff members against residents, including assault
and financial abuse. Ms Sullivan submitted that staff who refused to follow instructions to 'hit or
restrain clients' were victimised and bullied by supervisors and management. In 1989, Ms Sullivan
reported the abuse to community visitors administered by the Office of the Public Advocate.
Following the reporting of abuse, Ms Sullivan submitted that the department initiated an
investigation into the allegations. However, Ms Sullivan asserted that the allegations were not
adequately investigated:
What ensued was an absolute travesty…Only those of us who had spoken to
the CVs [community visitors] were called to the Regional Office for the
'inquiry.' No other staff including [name removed] were questioned.
No documentation or records were taken from Walpole by management.
Not one DHS [Department of Human Services] person from management
came to the CRU [community residential unit] or to even check on the clients
whose awful abuses we had described. No directive came from management to
have the clients medically checked. After we had given our evidence (which was transcribed, but never given to us
later as promised) we waited for an outcome or some contact from
management. Approximately 7 weeks later we were informed by [redacted],
Regional Manager, that "Allegations have been made but it was found there
was not a case to answer".
Ms Sullivan submitted that her experience as a whistleblower and the experience of attempting to
speak out against allegations of abuse took a significant personal toll:
I have diagnosed PTSD [Post Traumatic Stress Disorder], clinical depression
and other anxiety conditions. I also have adrenal fatigue, which I have been
told occurs when a person has endured a prolonged period of circumstances
which trigger ongoing "fight or flight" hormonal responses. Adrenal fatigue
has numerous and varied symptoms too lengthy to go into. I have become
reclusive, distrustful of others. I have lost my organisational and coping skills.
Source: Ms Julie Sullivan, Submission 157, p. [16].
5.28
In April 2015, as part of an investigation by journalists Mr Richard
Baker and Mr Nick McKenzie, government documents obtained by Ms Sullivan
indicated that the serious concerns raised by the Office of the Public Advocate
had been 'silenced', by the panel of inquiry established to investigate:
The panel substantiated the most explosive allegations,
including the unlawful use of restraints and soap suppositories, and expressed
"very serious concerns over programs and potential risk for
residents".
Yet it failed to interview everyone connected with the house
and quickly began laying a bureaucratic dead-hand over events, telling [the
then Community Services Minister Peter] Spyker that no staff had been negligent
and only "programmatic issues" had been identified.
Leaked files include one memo written by a public servant who
seems more concerned with bad publicity than the bad treatment of residents:
"Recommendations of the panel are designed to ensure that initiatives are
already being undertaken to minimise any adverse comment and present a positive
response to the matter".
Senior bureaucrats also moved to silence the Office of the
Public Advocate, with the panel of inquiry advising ministers that: "The
role of the Community Visitors in this matter is of grave concern in as much as
they have clearly moved into areas in which they appear to have no jurisdiction
nor should they seek to have jurisdiction".[23]
5.29
Ms Sullivan submitted that her continued attempts to have the abuse
investigated have not been supported by government:
The official stance...was that all claims had been investigated
and there was no evidence to substantiate. In reality, very little
investigation of our claims took place. The terms of the inquiry had been so
narrow and only limited to four of the lesser abuses.[24]
Box 5.2: Whistleblowers – Ms Karen Burgess
Ms Karen Burgess was a front-line disability services manager specialising in people with
'behaviours of concern' and 'complex behaviours'. At one time, Ms Burgess was a site manager at a
disability day centre in Melbourne. Ms Burgess raised serious concerns about a large wooden box
that was erected in 2014 to restrain people with autism, which management considered to be a
'desensitising box' intended to be used as a calming device. Ms Burgess ordered the box to be
dismantled once she started working at the facility. Soon after, Ms Burgess was dismissed from
her position.
Ms Burgess provided evidence to the inquiry on the toll taken on whistleblowers:
There are many staff that find themselves in this position and end up leaving the industry
because they cannot handle the types of situations they are confronted with. There is a lot
of pressure that comes to bear on people who are like me, who speak up and out against
the type of abuse that in happening in these institutions.
…
There was another staff member at [organisation name withheld] who was fired, two
weeks after my termination, because of also raising practice issues and concerns. She is no
longer making complaints because of the pressure that came to bear on her, but there was a
second staff member who was also fired in this period because she was making direct
complaints about concerns at this site.
Ms Burgess noted that there are already many laws in place to protect people with disability,
but these are not being followed. However, Ms Burgess recommended that there be an independent
body with the powers of investigation leading to prosecution.
Source: Nick Toscano, Beau Donelly, 'Wooden box built to calm autistic students and day centre',
The Age, 4 October 2015 and Ms Karen Burgess, Committee Hansard, Brisbane, 16 October 2015.
5.30
A number of submitters highlighted the need for greater support and
nationally consistent legal protection for whistleblowers who speak out against
abuse, violence and neglect.[25]
For example, United Voice recommended:
Nationally consistent whistle blower legislation must be
introduced to support and encourage workers to speak up without fear of being
persecuted or targeted by their employers where a report is made in good faith.[26]
Committee
view
5.31
It is clear from the range of evidence presented to this inquiry from
multiple submitters in different jurisdictions across Australia, that no single
state or territory has yet devised an acceptable system of disability service complaints
reporting.
5.32
Many of these processes allow organisations to self-determine whether an
incident requires reporting outside the workplace, leading to a clear conflict
of interest.
5.33
The sheer number of whistleblowers who came forward to this inquiry
shows that internal reporting requirements are either not being followed, or do
not go far enough to protect people with disability from violence, abuse and
neglect.
External reporting mechanisms
5.34
In addition to the internal reporting mechanisms that are managed by
disability service providers, there are a number of external mechanisms at the
Commonwealth, state or territory level for investigating allegations of
violence, abuse and neglect against people with disability. Table 5.2 outlines
the different mechanisms available in each jurisdiction.[27]
Table 5.2: External complaints, investigation/dispute resolution bodies for
people with disability
Jurisdiction
|
Agency
|
Role
|
Commonwealth
|
National Disability Abuse and
Neglect Hotline
|
Referral service for all allegations
of abuse or neglect
|
Complaints Resolution and
Referral Service
|
Referral service for complaints
about Australian Government funded disability employment and advocacy
services
|
NSW
|
Ombudsman
|
Investigates incidents of
abuse or neglect of people with disability supported accommodation, monitor
service providers and review the deaths of certain persons.
|
Official Visitors
|
Visit disability accommodation
and may report allegations of abuse or neglect.
|
Child Protection Helpline
|
Referral service for
allegations of abuse or neglect of children
|
Victoria
|
Ombudsman
|
Investigates complaints about
public agencies and may investigate individual allegations in state-run
facilities (may investigate funded providers on a case-by-case basis).
|
Senior Practitioner
(Disability)
|
Responsible for protecting the
rights of people subject to restrictive interventions and compulsory
treatment, and to ensure that the relevant standards are met.
|
Disability Services
Commissioner
|
Resolves complaints raised by
or on behalf of people who receive disability services.
|
Community Visitors
|
Visits accommodation
facilities and inquire into various matters relating to service delivery,
including whether the rights of people with disability are being upheld.
|
Queensland
|
Office of the Queensland
Ombudsman
|
Investigates complaints about
actions and decisions of public agencies.
|
Office of the Public Guardian
|
Investigates allegations of
abuse against adults with impaired capacity and children. Administers
community visitor scheme vulnerable adults in disability accommodation and
children and young people in out-of-home care.
|
WA
|
Ombudsman Western Australia
|
Investigates complaints about
actions and decisions of public agencies.
|
Health and Disability Services
Complaints Office
|
Investigates complaints about
health or disability service providers.
|
Council of Official Visitors
(mental health)
|
Visits individuals receiving
treatment in mental health facilitates and inspects hospitals and psychiatric
hostels.
|
SA
|
Ombudsman
|
Investigates complaints about
actions and decisions of public agencies.
|
Community Visitor Scheme
|
Visits and inspects disability
accommodation and supported residential facilities.
|
Health and Community Services Complaints
Commissioner
|
Investigate and resolve
complaints about health and community services, including disability service
providers.
|
Tasmania
|
Ombudsman
|
Investigates complaints about
actions and decisions of public agencies.
|
Health Complaints Commissioner
|
Resolve complaints about
health services
|
Anti-Discrimination
Commissioner
|
Resolves complaints of
discrimination, provides policy advice and support to government, promotes
awareness of rights and obligation and offers training and education.
|
NT
|
Community Visitors (mental
health)
|
Visits people receiving mental
health treatment and resolves complaints.
|
Health and Community Services
Complaints Commissioner
|
Resolves complaints about
health, disability and aged care services.
|
ACT
|
Public Advocate
|
Advocacy services for people
with disability and mental health conditions, including monitoring of
services for adults with disability.
|
Official Visitors
|
Visits disability
accommodation and supported accommodation to detect and prevent systemic dysfunction.
|
Disability and Community
Services Commissioner
|
Resolves complaints about the
provision of services for people with disability and/or their carers
|
Source: NDIS, Proposal for a National Disability Insurance
Scheme Quality and Safeguarding Framework, February 2015, Table 2.
5.35
As Table 5.2 highlights, the responsibilities and powers of external
agencies vary significantly across jurisdictions. A number of submissions
highlighted how the complexity of multiple reporting mechanisms affects the
ability of people with disability to report allegations of abuse. The
Commonwealth Ombudsman submitted:
...responsibility for each of these functions varies significantly
across states and territories, and some oversight bodies have greater powers
and resources than others to deliver timely and effective support to people
with disability. This creates a risk that people affected by violence, abuse or
neglect (or others who may wish to report it) may have difficulty identifying
which of the many options is the most appropriate in their circumstances, or
may receive quite different levels of support or protection depending on where
they live.[28]
5.36
For example, the Victorian Disability Services Commissioner highlighted
that misconceptions about its role were common and that it did not have the
powers some members of the community assumed:
We are aware some members of the community appear to be under
the impression that we have the power to conduct a general investigation into
the performance of service providers. In fact, our power to conduct an
investigation relates specifically to determining whether or not a complaint is
justified, particularly where we believe that the complaint is not suitable for
conciliation or an attempt to conciliate the complaint has failed and further
action is required.[29]
5.37
The committee also heard concerns about the efficacy of existing
external complaints mechanisms. The Disability Alliance submitted:
...these mechanisms have been found to have limited effect in
investigating, responding to, and preventing violence against people with
disability across the range of settings and spaces where such violence occurs.[30]
5.38
In particular, the committee heard concerns about the Commonwealth's
National Abuse and Neglect Hotline (Hotline)[31].
The Department of Social Services (DSS) noted that between July 2012 and
December 2014, 891 cases of abuse were reported through the Hotline, mainly
systemic, psychological and physical abuse, and physical neglect.[32]
The Civil Society Report asserted that the Hotline 'is a relatively weak
safeguard for people with disability as it operates without any legislative
base and therefore has no statutory functions, powers and immunities'.[33]
5.39
The Hotline is also limited by the agencies to which it can refer
complaints. Due to inconsistencies in the responsibilities of independent
oversight bodies, some callers are referred back to the agency responsible
for the alleged incident or allegation. Ms Samantha Connor told the committee
of the importance of a national independent mechanism to address all forms of
abuse reported to the Hotline:
...not all types of abuse, when you take it to the national
disability abuse hotline, are covered by the hotline. For example, if it is a
government organisation you are told to take that back to the government
organisation, and they will investigate themselves through their existing
processes. I think that asking government to investigate itself is a horrible
idea and that there should be independent investigation...Having the argument for
an independent statutory body looking down on the whole country and all of
those issues and having very, very clear sanctions and very clear guidelines: I
think we need to have some national legislation to make sure that happens.[34]
5.40
The committee heard there was a particular need to support and educate
people with disability about what constitutes abuse. Families Australia
recommended the development and implementation of 'targeted respectful
relationships programmes', highlighting:
Access to targeted respectful relationship programmes for
children and young people with disability and their families to support them to
understand and promote healthy and respectful relationships and to recognise
and report abuse and neglect is also essential.[35]
5.41
A number of witnesses and submitters highlighted that even where
reporting mechanisms might be available, many people with disability and their
families may be reluctant to report abuse due to fear of retribution from the
service provider. Ms Sharon Richards, from Advocare in WA, told the
committee:
...most of the time things are not addressed, because of the
fear of retribution in the facility. An older person who is already in a
facility is in a more vulnerable position. We have had numerous phone calls
from people who are moving their family from one facility to another rather
than actually putting in a formal complaint, because it is so hard to deal with
and the system does not lend itself in a supportive manner to the families.[36]
Box 5.3: NSW Ombudsman disability reportable incidents scheme
On 3 December 2014, the Disability Inclusion Act 2014 (NSW) came into effect, including
amendments to the Ombudsman Act 1974 (NSW) to introduce the disability reportable incidents
scheme (scheme) for reporting and oversight of the handling of serious incidents, including abuse
and neglect, involving people with disability in supported group accommodation.
The scheme requires that within 30 days of becoming aware of a reportable allegation or reportable
conviction, the Secretary of the Department of Family and Community Services (FACS), or head of
a funded provider, must give the NSW Ombudsman notice of the allegation and/or conviction.
Under the scheme, the Ombudsman is required to:
- receive and assess notifications concerning reportable allegations or convictions;
- scrutinise agency systems for preventing reportable incidents, and for handling and
responding to allegations of reportable incidents;
- monitor and oversight agency investigations of reportable incidents;
- respond to complaints about inappropriate handling of any reportable allegation or
conviction;
- conduct direct investigations concerning reportable allegations or convictions, or any
inappropriate handling of, or response to, a reportable incident or conviction;
- conduct audits and education and training activities to improve the understanding of, and
responses to, reportable incidents; and
- report on trends and issues in connection with reportable incident matters.
Between the introduction of the scheme and 25 August 2015, 437 matters were reported.
The reported matters included:
- 55 per cent (240) involving allegations of employee to client matters;
- 34 per cent (148) involving allegations of client to client matters;
- 10 per cent involving allegations relating to unexplained serious injury; and
- one per cent involving allegations of breaches to an apprehended violence order (AVO).
Source: NSW Ombudsman, Submission 29, pp 2–10; Mr Steve Kinmond, Community and
Disability Services Commissioner and Deputy Ombudsman, Committee Hansard, 27 August 2015,
pp 16–17.
Case study – New South Wales
Ombudsman
5.42
The committee heard that NSW has recently implemented a unique approach
to the reporting of serious incidents. In 2014, the NSW Government introduced
the disability reportable incidents scheme, the only legislated scheme in
Australia for the mandatory reporting and independent oversight of serious
incidents involving people with disability in supported accommodation (see Box
5.3).[37]
5.43
To complement the scheme, the NSW Ombudsman has also established a Best
Practice Working Group made up of disability leaders and subject-matter experts
to provide advice and support on sector-wide improvement and cultural change.
The working group is currently examining a range of issues including:
...staff screening and recruitment practices, the related need
for a workable information exchange regime, the availability of and access to
relevant commissions and expert advisers, assessing the capacity of individuals
to consent to sexual activity, support for victims with disability and, where
relevant, their family members and the criminal justice response to people with
intellectual disability.[38]
5.44
The Deputy Ombudsman, Mr Steve Kinmond, estimated that the notification
of abuse and neglect matters via the mandatory reportable incidents scheme was
over 10 times the number of matters that were received via the existing
complaints system.[39]
Mr Kinmond told the committee that of the 437 matters reported through the
scheme since its introduction in December 2014, there had been seven charges
made already, a number of which 'would not have been laid were it not for the
fact that we were involved'.[40]
Mr Kinmond noted:
...we expect that [number of finalised matters] will climb
substantially in the near future. But the fundamental test I have for my
staff—at this point in time in terms of the matters that we have before us—is
whether there are adequate steps being taken to protect not only the identified
victim for the purposes of the matter that we are looking at but also other
people who may be at risk. So the timeliness of our response to matters
pertaining to protection will be my early focus. And of course over time with
those numbers we then start to look at and track very closely whether what is
coming in the door is matched by what is being finalised. Otherwise, it becomes
unsustainable.[41]
Case study – Victorian Ombudsman's
investigation
5.45
In December 2014, the Victorian Ombudsman launched an investigation into
the capacity and capability of the oversight systems for disability services,
prompted by revelations in the media and concerns in the sector.[42]
Phase 1 of the Ombudsman's final report examining the effectiveness of
statutory oversight identified serious issues limiting the effectiveness of
existing oversight mechanisms:
...despite areas of good practice, oversight arrangements in
Victoria are fragmented, complicated and confusing, even to those who work in
the field. As a result there is a lack of ownership of the problem and little
clarity about who is responsible for what. In some areas there are overlapping
responsibilities between agencies and no clear understanding of the boundaries.
In others there are legislative barriers to sharing information or
jurisdictional gaps. Thus problems are regularly raised—including by many
well-meaning players in the system—but rarely fixed.[43]
5.46
The Ombudsman's report found that the response to an allegation of abuse
of a person with disability in Victoria:
...is not determined by the nature of the abuse or the
vulnerability of the victim; instead, it is determined by the institutional
arrangements governing the service within which the abuse occurred or which
agency took the complaint. Thus the focus of the response is not on the
individual but the process.[44]
5.47
Similarly, the Victorian Parliament's Family and Community Development
Committee interim report on its inquiry into abuse in disability services
noted:
...while there are sophisticated policies and processes in
place in Victoria for complaint handling and responding to disclosures or
allegations of abuse in disability services, the pathways for making complaints
and reporting abuse or neglect are complicated and often confusing. In particular...there
is confusion between the policies and processes for handling and escalating
complaints, and for the management of reportable incidents.[45]
5.48
The complexity of the available reporting pathways for complaints in
Victoria is highlighted in Figure 5.1, taken from the Ombudsman's report.
Figure 5.1: Disability Act complaint pathways in Victoria
Source: Victorian Ombudsman, Reporting and investigation of
allegations of abuse, Figure 1, p. 19.
5.49
The Ombudsman's report identified further inconsistencies in the way
different allegations of abuse are managed, such as:
- serious
incidents in SRS [supported residential services] are not subject to DHHS
[Department of Health and Human Services] incident reporting or review
procedures, despite this being a routine response for services operated by the
department or providers funded by the department;
- incident
reports concerning allegations of assault are provided to the DSC [Disability
Services Commissioner] if the perpetrator is an employee of DHHS or a funded
provider but not if they are a fellow resident, or if the incident occurred in
an SRS;
- some
funded providers follow the Public Advocate's guidelines for responding to
incidents of violence, neglect and abuse while SRS, other providers or
DHHS operated services do not; and
- Community
Visitors can inspect SRS or accommodation provided by DHHS or CSOs [community
service organisations], but not day services or TAC [Transport Accident
Commission] accommodation.[46]
5.50
Other issues identified by the Ombudsman included:
-
no single source of information or common framework in the
disability sector to guide the reporting of abuse;
-
no independent review of all serious incidents;
-
lack of consistent approach to investigating serious misconduct
by funded providers;
-
constraints on some parts of the system from sharing information;
-
limited appreciation of the importance of the role of advocates,
'manifest in its modest funding, as well as an inherent conflict in advocacy
services being funded by the department upon whom the recipients of the service
rely'; and
-
tension between the roles of the department [DHHS}, 'particularly
its dual functions as both funder/provider of services and regulator'.[47]
5.51
The Ombudsman made two key recommendations to address the lack of
consistent mandatory reporting, complex oversight arrangements, gaps in
oversight and lack of advocacy services:
-
establish, or transfer responsibility to an existing agency, for
a single independent statutory oversight body to incorporate mandatory
reporting, assessment and advocacy, community visitors, senior practitioner and
disability worker exclusion scheme; and
-
undertake a comprehensive assessment of the advocacy needs of
people with disability and transfer sufficient funding and responsibility to
the Office of the Public Advocate.[48]
5.52
The recommendations of the Ombudsman's report were supported by a number
of submitters and witnesses in Victoria. Mr David Craig, Project Coordinator
from the Victorian Advocacy League for Individuals with a Disability (VALID)
told the committee:
VALID supports the Ombudsman's recommendations for an
independent investigative agency that can bring a measure of coherence,
consistency and vigour to keeping people with intellectual disabilities safe.[49]
5.53
The committee also heard support for the Ombudsman's recommendations
across jurisdictions. For example, in Queensland, the Office of the Public
Guardian noted:
An independent complaints mechanism separate from funding and
service provision is a critical element of any protective framework to guard
against and prosecute cases of violence, abuse and neglect.[50]
5.54
However, some witnesses criticised the Ombudsman's report for not taking
a 'hard-hitting approach' towards perpetrators of abuse and violence.
JacksonRyan Partners, a Victorian disability consultancy, was critical that the
Ombudsman:
...failed to make findings detailing how those responsible for safeguarding
and those responsible for services should more aggressively deal with those who
commit abuse, neglect and violence...it is not systems and process that perpetrate
abuse, neglect and violence—it is people.[51]
5.55
Going beyond critiques of existing state and territory based complaints
bodies, the committee heard strong support for national, independent oversight
mechanisms to identify and respond to allegations and incidents of abuse,
violence and neglect. The Queensland Office of the Public Advocate (OPA)
submitted:
Integral to an effective system is the existence of
independent entities with strong investigative powers to handle complaints;
these entities should be removed from the service provider, or department or
agency funding the service.
Without such independent oversight and investigative powers
there is a danger that cultures of violence, abuse and neglect go unchallenged.
Apart from the service provider itself, even the department or agency
responsible for funding the service also has a vested interest. For this reason
there must be an independent statutory authority that can conduct
investigations into serious, systemic and/or unresolved allegations of
violence, abuse and neglect.
The independent entity or body should have powers to receive,
resolve and investigate complaints; request information and conduct
investigations both in response to complaints and of its own volition; report
on the outcomes of investigations and make recommendations and/or directions to
regulatory bodies concerning funding and registration of the service provider
subject to the complaint.[52]
5.56
The committee notes that the proposed quality and safeguarding framework
consultation paper discusses the role of external oversight under the NDIS:
A key issue for the scheme is whether there is also a case
for establishing a body with an independent oversight function to provide an
additional level of assurance for the NDIS. Such a body would provide a
leadership role across the NDIS to ensure that registered organisations hear
and respond to complaints and other feedback in positive ways.[53]
5.57
The role of the NDIS in establishing a national monitoring and reporting
framework is discussed in greater detail in chapter nine.
Community visitor programs
5.58
One effective external mechanism identified by the Victorian Ombudsman
was the volunteer Community Visitors program in Victoria. The Ombudsman noted
that program provides:
...an important protection at a minimal cost, and actively
foster[s] the social inclusion of people with disability in the community.[54]
5.59
Across all jurisdictions, the roles and responsibilities of community
visitor schemes differ widely. Some jurisdictions have community visitor
programs responsible for inspecting residential facilities for people with
disability. Other jurisdictions have community visitors for mental health
services only. The different roles of community visitor programs across
jurisdictions are outlined in Table 5.3 below.[55]
Table 5.3: Community visitor programs by jurisdiction
Jurisdiction
|
Agency
|
Visited sites
|
Capacity
|
Appointment
|
NSW
|
NSW Ombudsman
|
-
Disability accommodation
-
Assisted boarding houses
|
Part-time
|
Minister for Disability Services
|
Victoria
|
Office of the Public Advocate
|
-
Disability accommodation
-
Supported residential facilities
-
Mental health facilities
|
Volunteer
|
Governor in Council
|
Queensland
|
Office of the Public Guardian
|
-
Disability accommodation
-
Mental health services
-
Private hostels
|
Casual
|
Office of the Public Guardian
|
WA
|
Council of Official Visitors (established by WA Parliament)
|
-
Mental health services and
hospitals
-
Psychiatric hostels
|
Sessional (paid sitting fees and expenses)
|
Council of Official Visitors
|
SA
|
Community Visitor Scheme
|
-
Hospital emergency departments/acute
mental health units
-
Disability accommodation
-
Supported residential facilities
|
Trained volunteer
|
Governor
|
Tasmania
|
Office of the Ombudsman and Health Complaints Commissioner
|
-
Mental health facilities
-
Prisons and corrections
facilities
|
Volunteer
|
Principal Official Visitor
|
NT
|
Community Visitor Program
|
-
Mental health services and
hospitals
|
Sessional
|
|
ACT
|
Public Trustee for the ACT
|
-
Disability accommodation
-
Mental health facilities
-
Detention and correction
facilities
-
Therapeutic protection places
|
Part-time
|
Attorney-General
|
Source: Refer to footnote 54.
5.60
The committee heard from the administrators of a number of community
visitor schemes across jurisdictions.[56]
In Victoria, the OPA noted that between 2009‑10 and 2013-14, 880
incidents have been reported by community visitors, including 'troubling cases
of assault by staff, serious and unexplained injuries and people living in fear
of violence'.[57]
5.61
Submitters highlighted the benefits of community visitor schemes in
identifying incidents of abuse, violence and neglect.[58]
The South Australian Community Visitor Scheme suggested the implementation of
community visitor programs in all jurisdictions across all institutions:
...we think it is vital that there be Community or Official
Visitor programs to all institutions and residential facilities as an important
means to detect violence, abuse and neglect of people with a disability,
including those with a mental illness. Evidence from almost four years of
operating also suggests that our Community Visitors build trusting
relationships with not only service users but also staff who disclose many
issues of concern relating to the care and treatment of vulnerable individuals.[59]
5.62
Similarly the Queensland OPA submitted that community visitors should
have greater powers to investigate and refer complaints:
The Community Visitor Programs, or a similar inspectorate
should operate as an inquisitorial process in terms of identifying,
investigating and resolving complaints. These informal processes can be of
great benefit particularly to people with impaired capacity who may have
difficulty making complaints. However, they can and should have a role in
referring complaints to external, independent complaints bodies.[60]
5.63
However, Ms Susan Salthouse, an Official Visitor for Disability in the Australian
Capital Territory, told the committee that the scheme is limited in providing
ongoing support to vulnerable and isolated people:
Official visitors provide that additional safeguard but what
we can ascertain on a visit of about one hour, every six to nine months, is not
foolproof. There are levels of vulnerability with increased isolation from the
community.[61]
5.64
A number of witnesses expressed concern that reports made by community
visitors, particularly to government departments, don't necessarily result in
positive change. The Victorian OPA noted that its community visitors report
long delays in responses from departments to reports of abuse. In one case
cited by the Victorian OPA:
Community Visitors have been reporting serious and
significant issues at this house including staff abuse and misconduct since
2012 and, despite a service review by an external consultant, they report there
were no significant improvements to the environment by the end of 2014.[62]
5.65
Ms Pauline Williams from Action for More Independence and Dignity in
Accommodation highlighted that although facilities are regularly visited, and
issues regularly reported, issues are not resolved:
...in investigating all of the monitoring of the supported
residential services that has gone on, it has been clear that, time after time,
they have been non‑compliant. In some cases, visiting has happened
monthly for 34 months and they have still been non-compliant on issues like
medication dispensing, food quality, emergency services and safety procedures.
If time and time again, over many years, noncompliance is shown by a sector,
why is it still allowed to function? Why is it still licensed, registered
and supported by governments?[63]
5.66
Similarly, the Intellectual Disability Rights Service told the committee
feedback from its consultations found that people who had contacted community
visitors were frustrated with the outcomes:
While one caller was happy with action taken when a matter
was raised with the community visitor program of the Ombudsman, 3 other callers
raised their frustration with the long delays and process involved in
investigation. Two callers did not feel the Ombudsman had sufficient power to
achieve solutions to problems of neglect.[64]
5.67
Ms Sandra Guy, the parent of a Yooralla client in Victoria, expressed
frustration that reports made by community visitors may not result in action,
and that community visitors do not engage with the families of people with
disability to advise on the progress of reports:
The problem is that I cannot tell you how many times I have
called the community visitors in relation to the concerns at my son's house,
which have been going on now for six long years, and what happens is that they
might go to my son's house but you have no idea what went on. They might lodge
a report with the department and that is as far as it goes—end of story. What
you do not see is any change...They refuse to talk to families, and we do not
know what happened when they went or what was in the report. It appears to go
nowhere, because there is no change, despite these claims.[65]
5.68
Another concern was that the voluntary basis of the scheme in most
jurisdictions reduced the capacity of visitors to provide support to families.
Ms Colleen Pearce, the Victorian Public Advocate, told the committee:
The programs simply do not have the capacity to be in contact
with parents. Where parents are at a facility on the day when the community
visitors visit, they will talk to parents. But there is a lack of the capacity
of volunteers to follow up and provide information, giving out personal
telephone numbers—we are talking about 450 volunteers...We are lucky if our
volunteers get reimbursed for out-of-pocket expenses.[66]
5.69
Some submitters suggested that existing community visitor schemes
continue under the NDIS. The Victorian OPA recommended:
...the Community Visitors Program continue to be funded during
the NDIS transition period and, secondly, that existing state and territory
community visitor programs continue to have a mandate to operate in the context
of the full rollout.[67]
5.70
Other submitters suggested that the NDIS quality and safeguarding
framework should include a community visitor scheme.[68]
The Queensland OPA recommended that the NDIS framework should include:
...independent safeguarding mechanisms such as the Community
Visitor Program that can cast an independent eye over service arrangements and
that have the potential to seek out issues of concern for people with disability,
rather than requiring people with disability to independently navigate formal
complaints management systems.[69]
Mandatory reporting
5.71
A number of submitters and witnesses supported the introduction of an
independent, mandatory reporting process, such as the NSW scheme, in ensuring
incidents are adequately reported and investigated.[70]
The Law Council of Australia recommended in relation to elder abuse:
...that now is the time for Government to conduct a review of
mandatory reporting requirements and to strike an appropriate balance between
safeguarding against elder abuse and ensuring the regulatory burden on aged
care facilities are minimised.[71]
5.72
The Hon Kelly Vincent MLC, a member of the South Australian Legislative
Council representing the Dignity for Disability Party, told the committee she
strongly supports a mandatory reporting scheme. Ms Vincent noted that
legislation she has introduced into the South Australian Parliament to
introduce a mandatory scheme has not been supported by that Government:
The government is not amenable to it because it believes that
(a) it is better to have safeguarding mechanisms against abuse and (b) the
existing child mandatory reporting scheme is overburdened and basically broken
so it would be almost inefficient to implement another. My rebuttal to that
would be we certainly never said that it was either mandatory reporting or
safeguarding...The other point I would make in rebuttal to the government's
argument is, in terms of the child mandatory reporting mechanism already being
broken and therefore it not be worth doing anything else, if I break a window
in my house, I do not go through the house and break all the other windows so
that they match; I fix the window. I think perhaps rather than saying the
system is broken so we cannot do anything else, we could perhaps look at fixing
the system.[72]
5.73
The South Australian OPA emphasised that mandatory reporting is not
sufficient, and supported instead a system of 'mandatory response':
...that provides clear duties for all providers when they
become aware of a risk of abuse, or actual abuse. These duties may include
immediate action to keep a person safe, working with other sectors (e.g. the
police, or social work services), and a clear strategy of escalation and
reporting.[73]
A national approach to reporting
abuse
5.74
A number of submitters and witnesses recommended the establishment of a
national, independent, statutory body with powers to investigate and respond to
allegations of violence, abuse and violence against people with disability in
all settings. The committee heard support for such a body from a range of
stakeholders including public advocates and guardians, peak bodies, advocacy groups
and families.[74]
5.75
For example, Mr Damian Griffis, representing the First Peoples
Disability Network Australia as part of the Disability Alliance, told the
committee:
I think the answer is
pretty simple. An independent statutory body is the answer. That is something
that has been articulated by advocates for a long time, and I think its time is
well overdue. That is a critical part of the picture. One of the problems with
the National Disability Abuse and Neglect Hotline is its lack of
enforceability. It is just a reporting mechanism, really. So I think that is a
critical part of the puzzle, and I think its time is well and truly here—in
fact, it is long overdue.[75]
5.76
There were numerous proposals for the specific form such a body could
take. For example, the Disability Alliance recommended that a national body
should have the following functions:
- a 'no
wrong door' complaint handling function—the ability to receive, investigate, determine,
and make recommendations in relation to complaints raised;
- the
ability to initiate 'own motion' complaints and to undertake own motion
enquiries into systemic issues;
- the power
to make recommendations to relevant respondents, including Commonwealth and
State and territory governments, for remedial action;
- the
ability to conduct policy and programme reviews and 'audits';
- the
ability to publicly report on the outcomes of systemic enquiries and group,
policy and programme reviews, or audits, including through the tabling of an
Annual Report to Parliament; the ability to develop and publish policy
recommendations, guidelines, and standards to promote service quality
improvement;
- the
ability to collect, develop and publish information, and conduct professional
and public educational programs; and
- the power
to enable enforcement of its recommendations, including for redress and reparation
for harms perpetrated.[76]
5.77
Some submissions also suggested that a national body should also have
oversight of restrictive practices. Children with Disability Australia
recommended:
...the creation of a national body charged with monitoring and
reporting the use of restrictive practices, with the explicit aim of ensuring
restraint and seclusion is recognised as abuse and its use is reduced.[77]
5.78
The committee notes that oversight mechanisms are being considered by
the NDIA as part of its consultation paper on the proposed NDIS quality and
safeguarding framework. This proposed approach will be examined
in chapter nine.[78]
National safeguarding systems
5.79
Some submitters suggested adopting a system-wide approach to
safeguarding against abuse and violence against all vulnerable people, based on
models in the United Kingdom and Scotland. These models implement safeguards
across the health, social welfare and justice sectors to protect all 'at-risk'
adults, including those with disability.[79]
This includes early intervention approaches to identifying and reporting
incidents and allegations of abuse, violence and neglect (see Boxes 5.4 and 5.5).
Box 5.4: Scotland—Adult Support and Protection
Under the Adult Support and Protection (Scotland) Act 2007, Scottish local councils and a range
of public bodies are required to work together to support and protect adults who are unable to safeguard themselves, their property and their rights.
The Act defines adults at risk as people aged 16 years or over who meet all three of the following
criteria:
- are unable to safeguard themselves, their property (their home, the things they own),
their rights or other interests;
- are at risk of harm; and
- because they are affected by disability, mental disorder, illness or physical or mental
infirmity, are more vulnerable to being harmed than others who are not so affected.
The Act introduced measures to identify and protect individuals who fall into the category of
adults at risk. These measures include:
- requiring councils to make the necessary enquiries and investigations to see if action is
needed to stop or prevent harm happening;
- requiring specific organisations to cooperate with councils and each other about adult
protection investigations;
- the introduction of a range of protection orders including assessment orders, removal
orders and banning orders; and
- a legislative framework for the establishment of local multi-agency Adult Protection
Committees across Scotland.
The Act places a duty on councils to make enquiries about an individual's well-being, property or
financial affairs where the council knows or believes that the person is an adult at risk and that it
may need to intervene to protect him or her from being harmed. It authorises council officers to:
- carry out visits;
- conduct interviews;
- be accompanied by a doctor or nurse to carry out a medical examination in private; and
- require health, financial or other records to be produced in respect of the adult at risk.
The council can also apply for a protection order if they think the adult is at risk of, or is being
seriously harmed.
Source: Scottish Government, Adult Support and Protection,
http://www.gov.scot/Topics/Health/Support-Social-Care/Adult-Support-Protection; Scottish
Government, Act Against Harm, http://www.actagainstharm.org/ (accessed 23 September 2015).
Box 5.5: Care Act 2014 (UK)
In April 2015, the Care Act 2014 came into effect in the United Kingdom. The Act introduced
guidance on safeguarding vulnerable adults from abuse to replace the 'No Secrets' guidance
introduced in 2000.
According to the guidance, 'safeguarding' means:
…protecting an adult’s right to live in safety, free from abuse and neglect. It is
about people and organisations working together to prevent and stop both the
risks and experience of abuse or neglect, while at the same time making sure
that the adult's wellbeing is promoted including, where appropriate, having
regard to their views, wishes, feelings and beliefs in deciding on any action.
This must recognise that adults sometimes have complex interpersonal
relationships and may be ambivalent, unclear or unrealistic about their personal
circumstances.
The Act introduces mandatory reporting requirements that require local authorities to:
- make enquiries, or cause others to do so, if it believes an adult is experiencing,
or is at risk of, abuse or neglect. An enquiry should establish whether any action
needs to be taken to prevent or stop abuse or neglect, and if so, by whom;
- set up a Safeguarding Adults Board;
- arrange, where appropriate, for an independent advocate to represent and
support an adult who is the subject of a safeguarding enquiry or Safeguarding
Adult Review where the adult has 'substantial difficulty' in being involved in the
process and where there is no other suitable person to represent and support
them; and
- co-operate with each of its relevant partners in order to protect the adult. In their
turn each relevant partner must also co-operate with the local authority.
The safeguarding approach is underpinned by the following principles:
- Empowerment – People being supported and encouraged to make their own
decisions and informed consent.
- Prevention – It is better to take action before harm occurs.
- Proportionality – The least intrusive response appropriate to the risk presented.
- Protection – Support and representation for those in greatest need.
- Partnership – Local solutions through services working with their communities.
- Communities have a part to play in preventing, detecting and reporting neglect and abuse.
- Accountability – Accountability and transparency in delivering safeguarding.
Source: UK Government, Care Act 2014: Statutory guidance for implementation, Chapter 14:
Safeguarding, https://www.gov.uk/government/publications/care-act-2014-statutory-guidance-forimplementation
(accessed 23 September 2015).
5.80
The South Australian OPA noted the principles of its report on rights-based
protection for older people, Closing the Gaps, could be applied to
people with disability.[80]
The report found the current legal framework in South Australia:
...provides protective frameworks for serious cases of abuse
and for those who are particularly vulnerable due to mental illness or
incapacity, but it does not provide a framework for less intrusive methods of
intervention, or early intervention, and at a time when serious abuse or
neglect could be avoided. In these respects, the current legal system is not
preventative in nature and fails to provide an incremental approach to
intervention that recognises degrees of vulnerability falling short of complete
incapacity.[81]
Concluding
committee view
5.81
The evidence presented to this inquiry shows that existing internal and
external mechanisms for reporting abuse are complex and there is no national
consistency in how allegations and incidents are reported. This has had the
effect of both discouraging reporting meaning cases of abuse go unreported, as
well as reducing the efficacy of investigations.
5.82
The committee acknowledges the findings of the 2015 Victorian
Ombudsman's report and evidence from inquiry witnesses that existing mechanisms
are not effective in reporting and responding to allegations and incidents of violence,
abuse and neglect.
5.83
After reviewing oversight mechanisms across Australia, the committee
recognises the important role played by community visitor schemes. However, for
these schemes to be effective, most require better funding to improve training,
increased numbers of visits, increased capacity to communicate with families,
and to be granted the authority to report and investigate allegations and
incidents.
5.84
The committee recognises that a clear and consistent recommendation was
made by many submitters and witnesses, including government agencies, that
there is a need for a single, independent oversight body for all entities and
individuals providing services to people with disability, with appropriate whistleblower
protections.
5.85
In establishing such a national body, the committee recognises the value
of the NSW Ombudsman disability reportable incidents scheme. The committee
particularly notes the strength of this system is based on the mandatory
reporting requirements.
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