Inquest into the death of Rachel Martin

Case Number: 2017/00336274

Date of Findings: 21 October 2022

Magistrate: Deputy State Coroner, Magistrate Harriet Grahame

Catchwords: CORONIAL LAW – provision of respite care; carer ratios; carer training; transport related death.

Responses

Recommendations

To the SNAP Program Ltd:

1. Review, amend, or draft a staffing policy addressing hours an employee may work. It is recommended that the policy prevent any employee being rostered on for a period in excess of a double shift. A double shift represents two 8 hour shifts or in the alternative, a sleep over shift (where the sleep hour shift is not more than 4hrs + 8hrs sleep + 4hrs) plus a further 8 hour shift, without a 10 hour break between the double shift and the next shift, or as recommended by an expert in the area. It is understood that such a review would take into account the particular circumstances of staffing levels at camps and allow for exceptional circumstances.
2. To support a comprehensive understanding of any relevant regulations and the above developed staff rostering policy, it is recommended SNAP seek the support of an independent third-party advisor to:
   a) Deliver a session to the senior executive to understand broader risk implications in relation to staffing levels and related policies, legislative and regulatory requirements;
   b) Assess the appropriateness of the policy drafted in response to recommendation (1); and
   c) Deliver a workshop to staff and management to understand the risks around the associated policies and the failure to adhere to them. 
3. Develop a policy to address a process for staff to elevate concerns regarding staffing challenges, with such process to be independent of executives and managers;
4. Ensure that training in the character of PART, or similar training, become a part of a cyclic refresher training program delivered by SNAP to staff and to new employees as soon as practicable after completing their probation period. 
5. Update its transport policy to include the following:
   a) The transport driver should be provided with the details of an available contact person (hereafter referred to as ‘support person’) who can attend on the vehicle during that period of transport;
   b) Save for emergencies, a driver transporting a child or young person alone should not exit the vehicle whilst on a motorway, highway, or major public transport corridor. Where there is a need to pull over, such as where a child or young person is presenting a risk to safe driving or is a risk to other persons in the vehicle or themselves, emergency services or a support person should be contacted to assist in the safe access of the child or young person;
   c) Save for emergencies, whilst on a motorway, highway, or major public transport corridor, a driver transporting a child or young person alone should not open the vehicle’s door to access the child or young person. Where there is a need to pull over and obtain access to the child in the vehicle, such as where a child or young person is presenting a risk to safe driving or is a risk to other persons in the vehicle or themselves, emergency services or a support person should be contacted to assist in providing safe access the child or young person.
   d) Where there is a need to pull over and obtain access to the child in the vehicle, such as where a child or young person is presenting a risk to the safe driving, or a risk to other persons in the vehicle or themselves, emergency services or a support person should be contacted to assist in providing safe access the child or young person.