• Tue. Sep 20th, 2022

Royal Commission on the Disability: a medical error revealed

ByChad J. Johnson

May 18, 2022

Customers with disabilities relied on their childcare provider to take their correct medications, but an investigation has told this does not always happen.

A disability care organization did not notify authorities that customers had skipped their medication or taken it late because it did not believe it had to.

The Royal Commission on Disability has heard allegations about the management of the non-profit Australian Disability Foundation (Afford).

Wayne Adamson, a district manager in Afford who became national executive director, said he had received a number of reports from staff about failures to administer the correct drug.

“They were mostly in the daytime programs. They were missed by time but still administered,” he told the royal commission on Wednesday.

But Mr Adamson said his superiors understood the organization was under no obligation to report such incidents to the regulator, the NDIS Quality and Safeguards Commission, unless it was deliberate.

“Presumably it was never deliberate?” asked royal commission chairman Ronald Sackville.

“Yes,” replied Mr. Adamson.

“So the organization was not reporting.”

Mr Adamson also told the inquest the culture at Afford changed when the previous CEO left and a new one started, to reward staff and focus on financial success.

“It seemed like everything was based on the financial side of things, which is the job for team leaders and district managers,” he said in his statement.

“So whenever we had a meeting or there was some kind of conference, the first point of discussion was always about finances.”

Team leaders also received performance bonuses of up to $3,000 per year, and “buzz” parties were held as social events for staff.

Mr. Adamson agreed that the focus on finances put some pressure on each of the centers to ensure that they were performing well financially.

The president, Mr. Sackville, asked Mr. Adamson if he ever wondered why such a non-profit organization would put so much emphasis on financial success.

“No,” he replied.

Later, when he entered a management position, he was told “this is how it has always been”.

Mr Adamson said in his statement that there was also a culture under previous management in which Afford staff were reluctant to speak out for fear of being closed off, families were not a priority and the focus was not focused enough on promoting a safer environment for customers.

There was also a lack of understanding among staff as to what was needed to keep customers safe.

He said that as a district manager, it had not occurred to him that there were gaps in risk management policies.

“It didn’t cross my mind at the time,” Mr Adamson said.

“That seems a pretty hardcore attitude for someone who has responsibility for running seven units,” Sackville said.

“You understand, don’t you, that the highest priority should be the safety and well-being of program participants?”

“Absolutely,” replied Mr. Adamson.

Mr Adamson said that as district manager he knew nothing of the statutory framework that governed Afford’s day programs, for which he was responsible.

He described Afford as a “lean organization at the top” with much responsibility for security systems and procedures falling to team leaders or managers, with no framework responsible for security, risk or compliance.

“No team came in to look at the total number of incidents for the organization and to look at patterns or trends or anything like that,” he said.

Earlier, a senior Afford executive from 2015 to early 2020 pointed to continued pressure from the company’s former CEO, Steven Herald, to recruit huge numbers of staff, up to 50 a month, to keep up with Afford’s rapid growth.

Under the pseudonym of Rachel, she said that towards the end of her term she had growing concerns that staff promoted from direct support positions did not have the abilities to cope with leadership positions and that this could have an impact on quality of service.

‘Towards the end of my time at Afford, I became increasingly concerned that the safety and quality of our services and respect for clients’ rights were not the top priority,’ his statement read.

“It was run as a for-profit company, rather than a disability service provider.”

A first-of-its-kind civil proceeding against Afford was due to open in federal court on Wednesday over the death of 20-year-old Merna Aprem, but was canceled until May 30.

Ms Aprem, an NDIS participant, died in 2019 when she drowned in a bathtub while living in supported accommodation run by Afford in Woodbine, Sydney.

“This event highlighted a number of issues and concerns that I was starting to have,” Rachel said.

Afford had no central person or department overseeing quality, compliance or labour, health and safety, she said. It was assumed that each division would deal with these types of issues.

“I remember the CEO yelling at me for raising this issue and telling me that a compliance person would try to find reasons why Afford couldn’t open a new site or service, which would hamper growth,” Rachel said.

She told the inquest that when she raised the concern on a staff conference call, she was reprimanded once again by the CEO, who responded with words to “develop a spinal column”.

She sent a five-page report to a member of Afford’s board of directors expressing concerns about the risks and compliance of some team members, she said.

Shortly after, she was suspended and told it was because of complaints filed by co-workers.

Out of breath, she offered to quit instead.

NDIS Quality and Assurances Commission Registrar Samantha Taylor returned to the inquiry on Wednesday to answer questions about the commission’s auditing procedures.

Ms Taylor explained that there was no guarantee that a site auditor would receive information about complaints against a service provider before carrying out an audit, but said the NDIS commission was considering whether there should be to have some.

She explained that it is the responsibility of the NDIS commission to review complaints and reportable incidents and assess a vendor’s response to them.

“It’s not the job of auditors to assess whether a provider is providing safe services,” Ms Taylor said.

The royal commission pointed out that this may be a “blind spot”.

“What I’m looking for is whether the guidelines are adequate to ensure that the audit process really questions what needs to be questioned,” said Royal Commission chairman Ronald Sackville QC.

The commission was told on Tuesday of an NDIS participant who alleged he was “hosed like a dog” after getting dirty while receiving respite care.

Another investigation is underway into an Afford client who fell ill after allegedly being fed solid food contrary to his meal plan.

Afford took two years to notify the NDIS commission of the alleged “reportable” incident in July 2019, only doing so after an ABC report about it.

In light of these events, the NDIS commission asked Afford to conduct a review of any incidents that may be considered reportable.

“Afford operated on a very serious misconception of his responsibilities for reportable incidents, which involved the failure to administer proper medication,” Mr Sackville said.

“And yet, we see nothing to indicate that the auditors investigated whether Afford understood his core obligations.”

Ms. Taylor argued that this could be part of a maturing of the audit model.