Commissioner Rose Wall was critical of the fact that three support workers failed to follow policy. Photo: LANCE LAWSON / SUPPLIED
A disability support service has installed alarms on all its doors after a resident who went missing on her birthday was found more than a day later, cold and naked, less than a kilometre away from the facility.
The 32-year-old woman, who had an intellectual disability, was seen on CCTV footage wandering neighbouring properties in the early hours one night in 2020, however her disappearance didn't raise an alarm for another six hours.
The support service was found to have failed in its care to the woman, after the woman's sister, known as Ms A, made a complaint to the Health and Disability Commission (HDC).
In her decision - which was broadly accepted by the support service - Commissioner Rose Wall said the support service breached its own policies and she was also critical of the facility's communication with Ms A, during and after her sister, was in its care.
The woman, known as Ms B, who had an intellectual disability and has since died, was known to exhibit challenging behaviours and had a complex medical history, Wall said.
The facility where she lived was staffed 24 hours a day, seven days a week, with two support workers rostered on during the day, and one for a "sleepover shift" at night from 10pm til 6am.
Support workers were expected to keep Ms B in their "line of sight" while she was awake and de-escalate if she was displaying heightened behaviours.
On the eve of her birthday, Ms B was excited and awake - she was expecting a letter and planned to go for a birthday lunch, Wall said.
An incident report earlier that day noted she was "'shouting", "[raising] her voice", "using rude language", and "making loud noise".
"Medication was administered and staff instructed Ms B to '[calm] down and rest in her room'."
Later, shortly before midnight, the sleepover support worker found Ms B awake and distressed, gave her medication and told her to go to bed.
The support service told police that a check at 2am, found Ms B asleep in her bed.
However, Wall said this was contradicted by CCTV footage that showed Ms B on neighbouring properties 400m away from the facility between 1.30am and 2.20am.
In its own investigation the support service found that Ms B left the facility to check the letterbox - part of her normal routine - but became disoriented. The precise time she left couldn't be determined.
Wall said at 6am the sleepover support worker completed a handover, but didn't physically check on Ms B and neither did the two incoming day workers.
"The support service stated that this lapse in process was because staff had noted Ms B's agitation over the night ... and they wanted to allow Ms B to sleep in without disturbance."
Wall was critical of the fact that three support workers failed to follow the policy, which she said was clear and particularly important given Ms B's agitation the night before.
She said the failure amounted to a breach of the Health and Disability Code's standard of care and meant the alarm that Ms B was missing wasn't raised until a visual check at 8.30am.
Her disappearance was reported to police about 45 minutes later and to Ms B's family shortly before 10am.
Six additional staff deployed to help find her, in an extensive search undertaken by police and Search and Rescue teams.
Ms B was found the next day at 1.15pm about 800m (an 11-minute walk) from the residence, Wall said.
"Without any clothes, and she had a low body temperature, 'but otherwise [she was] OK'. Ms B was taken to hospital for treatment and observation."
In her decision, Wall noted that as soon as Ms B was reported missing, the incident was escalated and managed promptly, however she was critical of the quality of incident reporting.
Wall was also critical of the information provided to Ms A about assault allegations against Ms B and the adequacy of the documentation provided to Ms A when Ms B went to live with her following the incident.
She said the support service had since enforced handover expectations for staff, increased the number of staffing on each shift, including the night shift, and placed alarms on its facility doors which were activated if anyone leaves the house.
Wall acknowledged the improvements and also recommended the support service provide a written apology to Ms A and further training to staff around incident reporting, their roles and responsibilities, and documentation standards.
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