Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697643161408.pdf (Australia)
Submission to the Senate Community Affairs References Committee Inquiry Into Violence, Abuse and Neglect Attachment: E. 6.
E. ATTACHMENTS Neglect – Abuse – Violence -­ Death -­ JacksonRyan Partners – Max Jackson and Margaret Ryan May 2015 1 Violence, abuse and neglect against people with disability in institutional and residential settings, including thegender and age related dimensions, and the particular situation of Aboriginal and Torres Strait Islander people withdisability, and culturally and linguistically diverse people with disabilitySubmission 42 - Attachment 6 Submission to the Senate Community Affairs References Committee Inquiry Into Violence, Abuse and Neglect Neglect – Abuse - Violence - Death Living in Victoria’s disability accommodation sector equates to a game of chance.
If you are one of the 5,000 or so people with a disability living in one of Victoria’s supported accommodation houses then it equates to a game of chance whether your life will be okay 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 enquiry 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 some vulnerable people living in a support service called Plenty Residential Services (PRS) where some clients 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."
Figure 5 in the Beyond Doubt report, which is reproduced below, highlights that in the 2012-2013 year there was a total of 413 assaults and 113 incidents recorded as “behaviour”, additionally 65 Category One incidents were recorded as client deaths.

While the figures as recorded are significant it is important to understand why there appears to be a significant drop in the number of deaths in the 2012–2013 year compared with the three previous reporting years.
It would be wrong to assume that there had been a significant drop in the number of deaths.

What does need to be understood is 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 following is an extract from the Beyond Doubt Report – JacksonRyan Partners – Max Jackson and Margaret Ryan May 2015 2 Violence, abuse and neglect against people with disability in institutional and residential settings, including thegender and age related dimensions, and the particular situation of Aboriginal and Torres Strait Islander people withdisability, and culturally and linguistically diverse people with disabilitySubmission 42 - Attachment 6 Submission to the Senate Community Affairs References Committee Inquiry Into Violence, Abuse and Neglect Figure 5: Number of Category one critical incidents by incident type in Disability Services Category one incidents Client death Assault Behaviour Other Incident types 2009-10 208 287 46 451 2010-11 272 396 52 876 2011-12 156 439 91 1,010 2012-13 2013-14 65 413 113 1,199 Note: The 2013-14 figures have only recently been released and have therefore been inserted into the original table.
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.

Significantly it was determined that only those deaths that were 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.

The significance of this change goes beyond the figures.
Of equal significance is the fact the Department of Human Services does not make available the Category Two incident report 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.

The only conclusion must be that the 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 is likely to have been somewhere between 200 and 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 year across the disability accommodation sector.

However else this figure is considered it is must be considered as high.
As such, when the death figures are considered in concert with those figures reporting abuse and neglect and as provided in the Community Visitors Board report, the concerns as expressed in that report must resonate as a significant concern.
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 that of 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.

Indeed, 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 had been found guilty of the rape of clients in accommodation services managed by Yooralla.

A third case is due to come before the courts in late October this year and is worthy of note that this case not only also relates to Yooralla but also allegedly occurred in a day service managed by that organisation.
The objectives of the Disability Act include the promotion and protection of the rights of persons accessing disability services and also making “disability service providers JacksonRyan Partners – Max Jackson and Margaret Ryan 3 May 2015 Violence, abuse and neglect against people with disability in institutional and residential settings, including thegender and age related dimensions, and the particular situation of Aboriginal and Torres Strait Islander people withdisability, and culturally and linguistically diverse people with disabilitySubmission 42 - Attachment 6 Submission to the Senate Community Affairs References Committee Inquiry Into Violence, Abuse and Neglect accountable to persons accessing those disability services.” Therefore, given the call by the Community Visitors Board for an enquiry into abuse and neglect and the refusal of the Department of Human Services to release the total of the death figures occurring in supported accommodation tends to mock the Act’s objectives.
The evidence that supports the claim that abuse, neglect, violence and deaths error 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 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 must have a higher priority than that of establishing an enquiry into the neglect, abuse, violence and deaths occurring in residential facilities for people with disabilities.
Despite the state of Victoria having an Ombudsman, a Public Advocate, community Visitors, a Disability Services Commissioner, a myriad of funded advocacy organisations, strong legislative provisions and funding and contracts between the DHS and funded disability organisations, neglect, abuse, violence and deaths continue unabated.

It is now time to end the farce of pretending we, as a community, are truly concerned about the rights of people with disability.

It is time now for the government to act.


And, it is time for those entities that are paid to protect the rights and welfare of people with disabilities in residential facilities as well as those who attend day services, to stand up and be counted and do their job.

If the Community Visitors call for an enquiry into abuse and neglect in disability accommodation services is ignored then who will be a takes responsibility for addressing this social scandal.
Where will people with disabilities, their families and those concerned about the protection and rights 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 enquiry must be now.
************** JacksonRyan Partners – Max Jackson and Margaret Ryan May 2015 4 Violence, abuse and neglect against people with disability in institutional and residential settings, including thegender and age related dimensions, and the particular situation of Aboriginal and Torres Strait Islander people withdisability, and culturally and linguistically diverse people with disabilitySubmission 42 - Attachment 6