Safeguards against neglect of vulnerable adults critical, says State Coroner

The death of a 78-year-old Clayton woman following at least three years of neglect while in her nephew’s care has prompted Victorian State Coroner, Judge John Cain to recommend sweeping changes to the state’s safeguards for protecting at-risk adults from abuse in a finding published for the first time today.

CFT died of bronchopneumonia at Monash Medical Centre on 4 August 2020 after being admitted with septic shock the day prior. Paramedics reported that she was found malnourished, dehydrated and hypothermic, with her clothes soiled and faeces on her skin and nails.

At the time of her death, CFT – who had a complex medical history, including chronic schizophrenia, an intellectual disability and dementia – was being cared for by her nephew, RDS. RDS had been receiving a carer’s payment since 2009 when he took over care of CFT and her husband. Following CFT’s husband’s death in 2017, RDS had sole oversight over CFT’s health and wellbeing.

Reports of neglect of CFT were first recorded in 2017, when Mecwacare – one of CFT’s in-home aged care support services – registered concerns about her nephew’s failure to maintain her hygiene, nutrition and medical needs.

Judge Cain found that between 2017 and 2020, various service providers visited CFT on numerous occasions and observed that she was often in soiled clothing, had no access to clean continence pads and on one occasion had only newspaper to use instead of toilet paper. Records also stated that the house was unkempt, with signs of hoarding, and that RDS had, at times, acted aggressively and erratically towards care support staff – refusing entry to the home and not responding to calls for check-ups or GP services.

Reports were made to Seniors Rights Victoria (SRV), the Office of the Public Advocate (OPA) and Aged Care Assessment Services and in July 2019, Mecwacare applied to the Victorian Civil and Administrative Tribunal (VCAT) for a guardianship order for CFT. On 2 August 2019, VCAT approved a guardianship order, giving the OPA the power to make decisions for CFT about accommodation and access to services.

While CFT’s living conditions improved slightly for a time following the appointment of the OPA as guardian, intervention regarding her care was never adequately escalated and she remained living with RDS where her condition deteriorated until her death.

In the finding, Judge Cain observed that the lack of a comprehensive adult safeguarding framework in Victoria, left CFT and at-risk adults like her vulnerable to abuse, neglect and exploitation.

While there are numerous organisations who each play a limited role in adult safeguarding in Victoria – including SRV, the Elder Abuse Helpline, hospitals, the OPA, the NDIS Quality and Safeguards Commission, the Aged Care Quality and Safety Commission, and Victoria Police – Judge Cain said the current safeguarding system in Victoria was fragmented, without adequate escalation pathways and therefore at-risk adults could still “fall through the cracks.”

His Honour said that if adult safeguarding legislation and/or an agency were implemented in Victoria, CFT would have likely met the criteria for an adult safeguarding response due to her care and support needs, her cognitive impairment, her risk of experiencing neglect and her inability to protect herself.

“If [adult safeguarding legislation and/or an agency were] available, Mecwacare, another agency or any other person who was concerned could have reported their concerns to the agency, and the safeguarding agency would have the power to thoroughly investigate,” said His Honour.

In the finding, His Honour acknowledged that significant reviews had been conducted regarding adult safeguarding. Since 2017, the Australian Law Reform Commission, the OPA and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability have recommended the introduction of Victorian adult safeguarding legislation to establish adult safeguarding functions including assessment, investigation, and co-ordination of responses to allegations of neglect and abuse of at-risk adults.

Further, the Victorian Auditor General’s Office (VAGO) 2024 report Guardianship and Decision-making for Vulnerable Adults made 13 recommendations including that the OPA review and update its guidance to staff on allocating orders and on balancing the risk of harm when making decisions. While His Honour commended the OPA for accepting all VAGO’s 13 recommendations, he suggested more needed to be done to protect at-risk adults.

To prevent similar deaths, Judge Cain has today made 10 recommendations, directed to the Victoria Government and the OPA, focused on improving investigative powers and establishing adult safeguarding legislation. Recommendations included:

That the Victorian Government implement as a priority, adult safeguarding legislation to establish adult safeguarding functions including but not limited to the assessment and investigation of, and coordination of responses to allegations of abuse, neglect, and exploitation of at-risk adults.
That the Victorian Government make available appropriate funding to the OPA to enable it to implement all of the recommendations from the VAGO report.

A copy of the finding can be accessed here:
https://www.coronerscourt.vic.gov.au/sites/default/files/COR%202020%20004205%20Form%2038%20-%20Finding%20into%20Death%20without%20Inquest_deidentified%20FINAL%20.pdf

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