A damning report by the disability royal commission has found the South Australian Department of Human Services (DHS) failed to provide a safe home for two men with autism and intellectual disabilities.
In June 2021, the royal commission examined three cases in South Australia — Mitchell*, Daniel Rogers and Ann Marie Smith.
The commission found "inadequate institutional accountability" on the part of DHS for failing the men.
The report stated that Mitchell had been living in DHS-managed accommodation but his aunt and uncle started to become concerned after discovering he had injured his foot and was taken to a topless waitress restaurant by a staff member.
Letter threatened Mitchell's life
She raised concerns with DHS but felt they were never heard. A camera was also installed in Mitchell's room without the consent of his legal guardians, his aunt Victoria* and uncle James*.
"In an email, the Director of Accommodation Services acknowledged the inappropriateness of installing a device capable of videoing Mitchell in his unit without informing James and Victoria or seeking their consent," the commission stated.
"The director described the failure as a 'breakdown in communication' and apologised that appropriate approvals and safeguards had not been negotiated and documented before the intercom had been installed.
"As a consequence of the intercom issue and other matters, the site manager was moved from the residence. It appears that at least one staff member felt aggrieved by this change."
In March 2018, Victoria and James received a letter that threatened their 38-year-old nephew's life, which they reported to DHS and SA Police.
The letter also used a derogatory term for Mr Mitchell.
But the commission found DHS did not take the letter seriously enough, which caused delays in investigating who the author was.
"DHS failed to discharge its responsibility to take appropriate measures to find out the source of an apparently serious threat to the safety and wellbeing of a person with disability in its care," the report found.
The report stated that since the commission hearings in June 2021, DHS hired an external investigator to look into the letter and sent the family a formal apology.
DHS failed to investigate bruising
Mr Rogers, 40, had been in state government-run group homes for most of his life, but his mother Karen Rogers started to become more concerned about his treatment before he left in 2019.
The commission stated his mother found unexplained injuries on her son, insufficient medication for him when he went on holidays, poor grooming and personal hygiene and did not know how his money was being spent.
The inquiry also heard his room at the home had "an air of neglect" with dirty walls and floors.
In February 2019, disability workers outside of DHS discovered Mr Rogers had a large bruise across his lower back which appeared to have paint or dye obscuring the injury.
They reported it to the National Disability Insurance Scheme (NDIS) Commission.
"DHS failed to seek an urgent medical opinion about the nature and likely cause of Daniel Rogers' injuries."
The commission found Mr Rogers was neglected by DHS, rejecting submissions by the state government during the hearings that his treatment was at times "unacceptable" but did not amount to neglect.
DHS has also apologised to the family of Mr Rogers.
Ann Marie Smith death was examined
The commission also looked into the response by both the South Australian government and the NDIS since the death of Ann Marie Smith, who suffered prolonged neglect while receiving support by provider Integrity Care.
It examined two reports — one commissioned by the government, the other by the NDIS Commission — since Ms Smith died at her Kensington Park home in April 2021.
The royal commission identified areas that still needed further investigation, including communication between NDIS providers and people living with disability and how services could improve their quality and become more "person-centred".
"It is not enough for a policy to claim to be person-centred," the commission stated.
"Person-centred approaches must be embedded in day-to-day practice and cultures of all those responsible for the delivery of service."
*Michell, Victoria and James preferred the use of pseudonyms
