Acknowledge, answer, action, apologise

Day 10 #WCMTLD today, feels like time is flying by. Today I visited the Office of the Disability Services Commissioner (ODSC) in Melbourne. I got to spend time with their Systemic Review Team, who are a very newly formed (still forming) team charged with looking into reviewable deaths. The Disability Act 2006 was amended in August this year, and additional powers were given to the Commissioner, Laurie Harkin, to investigate any matter relating to the provision of services (including abuse or neglect in the provision of services) by service providers identified in notifications of death received from the Department of Health and Human Services, or by the State Coroner.

The Systemic Review Team, Fiona, Christine, Erin and Eveline, are undertaking the individual investigations of service provision to people who were receiving disability services at the time of their death. The individual investigations will also inform the Commissioner’s annual review report, which will report on themes and systemic issues to improve the provision of disability services. The team are still polishing their procedures and they’re likely to adapt with time, but they expect to receive approximately 150 notifications a year. These are dealt with in two phases:

Phase 1: service providers are asked to complete a comprehensive questionnaire and provide documents to the ODSC, these are then reviewed by the team and a decision make about whether any further investigation is required

Phase 2: if a decision is made to progress then there are a range of actions that the team can take, including site visits, requesting of further information, speaking with people with disabilities and/or their Guardians, photographing and filming the homes and interviewing staff.

Regardless of whether solely a Phase 1 investigation, or also a more in-depth Phase 2 investigation takes place, a report is made from the Disability Commissioner to the Minister for Housing, Disability and Ageing and the Secretary of the Department of Health and Human Services.

We had a useful discussion about family engagement in the review process. Currently families are only informed if a Phase 2 investigation takes place and the process for that is being developed as we speak. The team were concerned about when best to contact families and how to ask some questions without putting pressure on or doing anything to illicit guilt amongst families. Anyone who has been following #JusticeforLB will know that the team are right to be concerned about issues of guilt or blaming families, although my response was what I’ve been told several times by bereaved family members ‘the worst thing has already happened, you can’t say anything that will make it worse, the worse thing is to not say anything at all’.

The team had prepared a number of questions for me, most of which we discussed, but I’ve promised more feedback and input by email. It felt like a really useful discussion for me, and I hope them, as they are keen to ensure that they involve families, as far as their powers allow.

Following that meeting I had the opportunity to meet with the Commissioner, Laurie, his Deputy Miranda, and Samantha from their Capacity Development Team. They explained some of the context and history of their office and the development of new responsibilities. They alerted me to their occasional papers series which includes one on Families and service providers working togetherThey also flagged that a lot of their responsibilities will be moving over to the Quality and Safeguards Commission, likely by mid to late 2019. This national body will play a key role in due course and is likely to streamline processes, I just hope that they are able to capture the learning and what works well from the ODSC and indeed the NSW Ombudsman, and the other teams that they are inheriting functions from.

Samantha gave an overview of the educational and capacity development activities of the ODSC. It was really heartening to hear such a strong focus on developing capacity in the sector and improving experiences for disabled people and their families. There was much to think on from both meetings but I’ll leave this post with a picture of a very self explanatory postcard, the 4As. Samantha was able to talk to the power of having a structure around which to resolve complaints, given all that families have told me previously about their experiences of the NHS once a relative dies in its care, I feel very certain that such a framework would help in such situations too. So simple, yet seemingly so hard to do:


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