Case Number: 2019/272828
Date of Findings: 28 February 2025
Magistrate: Deputy State Coroner, Rebecca Hosking
CORONIAL LAW – s 24(1)(e) Coroners Act 2009 (NSW), disability support services, the need for risk identification and assessment, the interaction between the views of the guardian and carers for persons with a disability, risks identified with drowning, risks identified with seizure activity.
Responses
| Recommendations to | Response |
|---|
| Interaction Disability Services Pty Ltd | Received (PDF, 353.0 KB) |
Recommendations
To Interaction Disability Services Pty Ltd (IDS)
- That, as part of its existing audit processes, IDS conduct an audit of progress note documentation for participants of the 24 Church Street, South Windsor group home (Church Street) to ensure that support workers are recording accurate and timely notes.
- That IDS conduct a review of the behavioural support documentation for its participants to ensure that:
- The behavioural support documentation itself provides clear guidance to staff as to risks and strategies to manage behaviours of concerns (including in the format of a single summary document)
- The language employed in documentation in connection with supervision requirements for participants in more precise than terms such as “spot checks” and “periodically” (so as to require further explanation, including as to the timing, frequency and nature of such checks).
- That IDS continue to develop an updated form of ‘Client Personal Profile’ document to ensure it:
- Includes an “All About Me” support plan based on the participant’s and stakeholders’ input
- Sets out the participant’s support needs and response strategies in a summary format
- Accurately references other critical support documents that provide instructions to staff (for example, a behaviour support plan or risk assessment).
- That IDS review the medication administration practices within its supported accommodation to ensure that:
- Medication charts are appropriately completed for participants; and
- Only support workers who administer medication sign the medication chart.
- That IDS engage a neurologist to review current epilepsy and seizure management policies and procedures.
- That IDS review its present ‘Family Involvement and Maintenance of Relationships policy’ with a view to including a section that provides guidance on conflict between family members and/or guardians and support workers as to concerns about the participant’s health, including clear guidelines for escalation to IDS management.
