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Royal Commission publishes hearing report on cases of Ann-Marie Smith, Daniel Rogers and ‘Mitchell’

Today the Disability Royal Commission releases its report, ‘Preventing and responding to violence, abuse, neglect and exploitation in disability services (South Australia)’, which considers the evidence given by witnesses during its fourteenth Public hearing, held in Adelaide from 7 to 11 June 2021.

The report includes an examination of the South Australian and Australian governments’ responses to the reports of two inquires (the Robertson and Safeguarding Reports) into the shocking death of Ms Ann-Marie Smith on 6 April 2020.

The key issues identified in the Public hearing 14 report include:

  • risk management
    • whether a person should be designated with overall responsibility for NDIS participants at heightened risk of harm
    • NDIS participants living alone and sole carers
    • potential for conflict of interest
  • information sharing between the state of South Australia, the NDIA and the NDIS Commission

The responses of the South Australian Department of Human Services (DHS), NDIS Quality and Safeguards Commission (NDIS Commission) and National Disability Insurance Agency (NDIA) to the recommendations made by the two inquiries are also addressed.

The report also examines two case studies involving ‘Mitchell’[1] and Daniel Rogers, two South Australian men living with autism and intellectual disability, who were residents of supported disability accommodation operated by DHS.

Both were victims of traumatic incidents in 2018 and 2019 which the Royal Commission found DHS had failed to properly investigate.  ‘Mitchell’s’ guardians ’ received an anonymous letter threatening harm to ‘Mitchell’, and Daniel had unexplained bruising on multiple occasions.

The report makes nine findings in relation to DHS, including that it failed to provide a person-centred approach in responding to the cases of ‘Mitchell’ and Daniel Rogers, and that there had been a lack of institutional accountability in DHS’s responses to both men’s experiences.

The report concludes by identifying the following areas for further investigation:

  • factors that identify a person with disability as being at higher risk of violence, abuse, neglect and exploitation
  • person-centred approach to service delivery
  • improved communication between service providers, regulators, people with disability and their families
  • quality of services
  • community visitor schemes
  • providers of last resort

Please direct all inquiries to the Disability Royal Commission Media team on 0436 841 166 or via our email


[1] A pseudonym.