Behind Closed Doors: The human cost of neglect in Victoria's support services


The Public Advocate, Dr Colleen Pearce, has shed light on the distressing state of affairs for adults with disability and mental health issues in Victoria.  

The 2022-2023 Community Visitor Annual Report, presented in Parliament this week, underscores the grave consequences of staffing shortages, limited services, and inadequate accommodation options, leading to heightened risks of violence, abuse, and neglect of Victorians with disability and mental health issues. 

The report discloses troubling instances of abuse, neglect, and violence within disability group homes, Supported Residential Services (SRS), and inpatient mental health facilities. Against the backdrop of the Disability Royal Commission's final report, Dr Pearce, Chair of the Community Visitors boards, emphasises the adverse impacts of congregating and segregating individuals with disability and mental health issues. 

Examples cited in the report include: 

  • a resident left in a soiled continence aid for up to 3 hours, due to insufficient staffing 
  • residents being injured due to rough handling or neglect by staff 
  • violence between residents that has persisted for years 
  • allegations of sexual violence and harassment  
  • medication errors 
  • shared bathrooms that were in urgent need of repair with broken tiles, broken toilets, leaking plumbing and mould on floors and ceilings 
  • a mental health consumer being told he was too acutely unwell to receive a second opinion, event though he was entitled to one. 

“Too many people experience ongoing abuse and neglect with few alternative accommodation or mental health facilities available,” Dr Pearce said. 

“Staffing shortages have created the conditions for violence, restrictive practices, neglect and a lack of services available for people who need them most.” 

In 2022-2023, 384 volunteer Community Visitors visited 1270 facilities identifying 5713 issues over 3793 visits. Abuse, neglect or violence accounted for 596 of the issues raised with service providers. 

Community Visitors also reported that many of the facilities visited were badly maintained and needed significant refurbishment and repair. This included leaking roofs, mouldy ceilings and walls, broken paving and stairs, broken or missing furniture, inadequate heating or cooling and accumulated rubbish.  

Some SRS residents were living in buildings that were unsafe or not fit purpose. One disability group home resident had to leave his wheelchair outside because the provider would not pay for alterations to the front door and step, and a mental health consumer told Community Visitors meetings with clinical staff were held in open areas. 

“Privacy and dignity are fundamental rights,” Dr Pearce said. “These rights include confidentiality, being treated as an individual, and recognition and respect for culture, identity, beliefs, and choices.” 

Dr Pearce also reflected that, “for more than 35 years now, Community Visitors have reported on good and poor practice in the places people with disability and mental health issues live and receive services in Victoria” as “ordinary community members with an extraordinary purpose”, congratulating them on their commitment and tenacity. 

The Community Visitor's Annual Report also included examples where good practices by staff led to residents building skills and making their own choices in their day-to-day life. 

“On the positive side, I would say: There are many promising changes on the horizon. There are also legislative changes in mental health and disability, and a new so. We look forward to the government's responding to the Disability Royal Commission’s final report and the recent NDIS Review. We must hold them to account.” 

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