Deputy Health and Disability Commissioner Rose Wall today released a report finding a disability care coordinator in
breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to arrange a support
worker to meet a vulnerable boy at a bus terminal, and thus leaving him unattended.
The boy, who has total blindness, was in his early teens at the time of the event. He was due to be picked up from a
public bus terminal by a support worker after school. A support worker did not attend, and he was left at the terminal
on his own, until a member of the public noticed the boy by himself and telephoned his mother for him.
The boy’s service plan with the disability service he was using noted that he was a falls risk and needed "constant
supervision to be safe".
The disability service that the care coordinator worked for conducted an internal investigation, which found that the
scheduled support worker had advised the care coordinator that he would be unable to attend the shift. The care
coordinator had taken actions to book a relief support worker, but did not communicate with the proposed relief support
worker or inform the boy’s mother of the changes to the shift.
Deputy Commissioner Rose Wall found that by failing to arrange a support worker to attend the boy - a vulnerable
consumer - the care coordinator did not provide services to the boy with reasonable care and skill.
"While the care coordinator’s error was administrative and unintentional, it was a fundamental aspect and requirement of
her role, and resulted in the boy being placed in a vulnerable and potentially dangerous position," said Ms Wall.
Ms Wall recommended that the care coordinator provide HDC with her reflections and learning from the incident, and
provide a written apology to the boy and his mother.
While the disability service was not found in breach of the Code, Ms Wall considered that valuable learning could be
taken from the case. She recommended that the disability service provide HDC with an update on the implementation and
effectiveness of various initiatives and changes made, and provide evidence of, or the outcome of, its consideration of
further initiatives for improvement in relation to leave processing and systems improvement for arranging relief support
workers. She also recommended the service consider the possibility of further systems improvement in relation to
communication by support workers to care coordinators when they are unable to attend a shift, to further minimise the
risk of human error.
Ms Wall recommended that the service review the effectiveness of systems in place to raise issues with senior staff,
provide the outcome of this review, and use the findings of the complaint as a basis for training staff.
The full report on case 18HDC00874 is available on the HDC website.