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Report - Public hearing 14 - Preventing and responding to violence, abuse, neglect and exploitation in disability services (South Australia)

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Report of Public hearing 14: Preventing and responding to violence, abuse, neglect and exploitation in disability services (South Australia)


The Disability Royal Commission held a public hearing in June and September 2021.

We have written a report about this hearing. This video is a summary of that report.

The hearing looked at the experiences of people with disability receiving support services.

The hearing examined how:

  • South Australian Department of Human Services (DHS)
  • National Disability Insurance Agency (NDIA)
  • National Disability Insurance Scheme Quality and Safeguards Commission (NDIS Commission)

responded to violence, abuse, neglect and exploitation in South Australia.

The hearing was held in two parts. Part 1 looked at the experiences of two men and Part 2 concerned one woman.

Part 1 looked at the experiences of Mitchell (not his real name) and Daniel Rogers. They lived in different supported accommodation in Adelaide that were both operated by DHS.

Mitchell and Daniel live with autism and intellectual disability, and have high support needs.

In March 2018 Mitchell’s guardians received a cruel and malicious letter. The letter threatened Mitchell with abuse and violence.

In February 2019 Daniel experienced significant bruising on his body, including his arm, buttocks and lower back.

Part 2 of the hearing concerned the death of Anne-Marie Smith in 2020. Anne-Marie received NDIS services. She died in terrible circumstances after a period of neglect.

The hearing specifically looked at the South Australian and Australian Government responses to two inquiries that were held following Anne-Marie’s death, and what changes were made as a result of these inquiries.

Findings and key themes

The report includes several findings from the hearing.

In relation to Mitchell’s case the Royal Commission found:

  • DHS did not take the letter seriously enough. DHS did not start investigating who the author was straight away.
  • When DHS did investigate the letter, its investigations were deficient and not thorough.

In relation to Daniel’s case the Royal Commission found:

  • DHS’s response to Daniel’s injuries was deficient and its investigation into how he got injured was slow. Information DHS recorded about the injuries was inaccurate.
  • DHS did not get advice from doctors about what caused Daniel’s injuries.
  • Daniel experienced neglect. This included poor personal hygiene and grooming, and a dirty house.

With regard to the case studies of both Daniel and Mitchell, the Royal Commission found:

  • DHS failed to adopt a ‘person-centred’ approach to their care.
  • DHS did not take proper responsibility for failing to care for them, and the experiences of their families.

In relation to Ann-Marie Smith’s case, the Royal Commission found three key issues that came out of inquiries responding to her death:

  • The NDIA and NDIS Commission need to do more, and have better ways, to identify people with disability who are at high risk of violence, abuse, neglect and exploitation. 
  • The NDIA and NDIS Commission need to put safeguards in place once a person has been identified as being at high risk of abuse or neglect, eg having more than one worker to support a person living alone.
  • There needs to be better information sharing between the South Australian Government, the NDIA and the NDIS Commission to reduce the risk of harm for people with disability.

More information:

To read the full report and for more information, visit our website. Search ‘Public hearing report 14’.