Investigative Report into Docker River

Investigative report conducted by the Aged Care Commissioner, Rhonda Parker, in relation to the death of a female Aboriginal elder at Tjilpi Pampaku Ngura (Docker River) Flexible Aboriginal Aged Care Service (the Service) in 2007 and the Department of Health and Ageing's handling of the service.

Page last updated: 22 December 2008

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Ministerial Request

1. On 22 September 2008, the Australian Broadcasting Company (ABC) published stories, in both written and multimedia formats, in relation to the death of a female Aboriginal elder (the Elder) at Tjilpi Pampaku Ngura (Docker River) Flexible Aboriginal Aged Care Service (the Service) in 2007 and the Department of Health and Ageing's (the Department) handling of the service.

2. You wrote to me on 23 September 2008 asking me to conduct an assessment of the Department's handling of the Service and the death of the Elder. In addition, you asked that I report to you on the actions of the Department leading up to, and after, the incident, beginning with the complaint issues raised about the Service by Ms Maggie Kavanagh from NPY Women's Council in early 2005, through to the recent provision of monitoring of the staffing at the facility – particularly at night. You also invited me to provide any additional recommendations or advice that I believed were necessary. You asked me to report to you as a matter of urgency.

3. The functions of the Aged Care Commissioner prescribed by s 95A-1(2) of the Aged Care Act 1997 (the Act) include advising you, at your request, about matters relating to any of the matters set out in ss 95A-1(2)(a)-(d) of the Act. As Docker River is not a service funded under the Act, you have asked me to conduct the assessment as an eminent person with an understanding of aged care and Indigenous issues.

4. As noted above, the scope of this investigation appropriately excludes the examination of the death of the Elder. However, I wish to express my sympathy to the family of the Elder. I also acknowledge the distress caused by the nature of the death to the family and other members of the community.Top of page


The Policy Context

5. While this investigation does not have a full set of documents cataloguing the evolution of the policy framework for the flexible aboriginal aged care services, and as such the context for examining the Department's handling of the Docker River Flexible Aboriginal Aged Care Service, a review of the six documents provided allows for an overview for the purpose of this report.

6. The six policy documents provided to this investigation are:
    • Aged Care Services for Aboriginal and Torres Strait Islander Communities – 1994 Budget Initiative.
    • Towards a New Paradigm in Indigenous Australian Aged Care – Strategic Directions Forum Discussion Paper (March 2003).
    • National Aboriginal and Torres Strait Islander Aged Care Providers Workshop Report (November 2003).
    • State and Territory Office Aged Care Business Improvement Project Report on Aged Care Programs for Aboriginal and Torres Strait Islander People (October 2006).
    • DoHA Aged and Community Care Division - Remote and Indigenous Service Support Initiative (2008)
    • Memo re Development of Quality in the Flexible Programs – Director Cultural and Flexible Initiatives (May 2008)


The Strategy

7. The Docker River Flexible Aboriginal Aged Care Service was established as a pilot and was the first of 30 flexible services set up under a 1994 initiative called the National Aboriginal and Torres Strait Islander Aged Care Strategy. This subsequently became known as the Strategy.
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8. The stated aims of the Strategy were to: provide flexible development, supported training and education, and financial support to indigenous aged care services. There was also a stated need for management support for the services. Documents stated that this initiative was to be a whole-of-government approach responding to the challenge of providing aged care to Aboriginal and Torres Strait Islander populations.

9. The Strategy recognised the need for aged care services for indigenous older people in often remote, isolated or small communities. The 'cashed out' funding model reflected the commitment to build flexibility into the system.

10. The key flexibility requirement of the Strategy, however, was to provide a culturally appropriate service to older indigenous people that would enable them to age and die in country, with the support of government funded aged care services in their own community. These services became known as 'flexible services'. To allow for such flexibility, the services provided by the Strategy would not be auspiced under the Act, but under the authority of a budget minute and contracting arrangements.

11. As such, the policy and program approach was avant-garde. While not a problem in itself (indeed the challenge demanded something different), there were inherent risks involved that would need to be closely monitored and managed.

March 2003

Towards a New Paradigm in Indigenous Australian Aged Care

12. This national workshop over two days was designed to 'address current and future provision of aged care for Aboriginal and Torres Strait Islander communities'. The key issues to be addressed were listed as:
    • long-term sustainability and capacity building;
    • culturally appropriate aged care;
    • care standards; and
    • workforce development.
13. The discussion paper prepared for the forum noted, among other things:
    • The 1994 flexible initiatives had never been formally reviewed.
    • The growth in the number of care places in the flexible services was from 27 places in 1996 to 485 places in 2002.
14. In the section under Standards of Care and Continuous Improvement, the discussion paper notes that while Aboriginal aged care services funded under the Act have 'protective mechanisms in place', in contrast, the 'flexible aged care services funded under the Strategy have no such protective mechanisms', and 'the potential exists for differing standards of care between those services under the Act and those services funded under the Strategy'.
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15. Among the strategies suggested for consideration at the workshop were:
    Development of monitoring and evaluation systems for flexible services.
    Requirements for audited financial statements for flexible services.
    The establishment of a National Aboriginal and Torres Strait Islander Aged Care Advisory body.

November 2003

National Aboriginal and Torres Strait Islander Aged Care Providers' Workshop Report

16. The Future Directions section in the report sets short, medium and long term commitments.

17. The one medium term commitment was to conduct a formal review of the Strategy.

18. One of the four long term commitments was to commence development to incorporate flexible funding and service delivery conditions for inclusion under the Act. The other long term commitments included the development of new funding and service delivery models for the services under the Strategy.

19. The report also catalogues the key recommendations of the Workshop. I note these particular pages in the report were water-marked 'draft only'. The recommendations included:
    • Conducting a review of the effectiveness, efficiency and ongoing relevance of the flexible services.
    • Following the review, identify options for future funding and service delivery models, including examining the merits of the flexible services operating under the Act.
    • The development and implementation of a Quality Assurance Framework to address the quality of care provided to Aboriginal and Torres Strait Islander communities. The report noted that 'to date there have been no formal monitoring processes in place to ensure consistent standards of care for aged care services funded under the National Aboriginal and Torres Strait Islander Aged Care Strategy'.

October 2006

State and Territory Office Aged Care Business Improvement Project – Report on Aged Care Programs for Aboriginal and Torres Strait Islander People

20. As part of the state and territory office's (STOs) business improvement project the STOs undertook and reported on a risk assessment of the Aboriginal and Torres Strait Islander aged care programs.
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21. The report grouped recommendations in three key areas of policy, program and compliance.

22. Regarding policy, the report included a recommended consideration of the future direction of the Strategy.

23. Regarding program administration, the report recommended priority be given to 'the development of national program guidelines and processes' to 'ensure consistency in the delivery of programs'.

24. Regarding compliance, the report recommended that a nationally consistent approach be developed to monitor, assess and review compliance of the services provided under the Strategy.

25. The report goes on to list specific recommendations including:
    • A review of the Strategy.
    • The development of standards of care.
    • The development of a minimum standard service model.
    • Consideration of a consultancy to visit each flexible service provider to assess the standards of care, make recommendations for improvement and develop a strategy to address the outcomes of visits.
    • Consider the 2003 suggestions regarding a cultural mentoring service.
This internal report was used to inform the minute for the 2007 budget process applying for funds for a support program for indigenous aged care services.


DoHA Aged and Community Care Division Remote and Indigenous Service Support Initiative (RISS)

26. In 2007 $42.6m was allocated for the RISS initiative. The three components to the package were:
    • Physical infrastructure - $7.7m.
    • Development and support for services - $34.9m.
    • Developing a more sophisticated and shared understanding of service delivery models and quality frameworks in Aboriginal and remote aged care.
27. The Department commissioned consultant Robert Griew to assist in shaping and implementing the initiative by developing these broad ideas. The initial report by the consultant in early 2008 provided a summary of the research and discussion regarding the RISS initiative.
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28. Regarding quality accountability, the report notes that the flexible services and the Department 'are exposed while the ambiguous status of quality accountability for …services remains.' It also notes the Aboriginal providers want a peer assessment model and do not want a process with a 'paperwork orientation'.

29. The consultant suggests a new set of standards for the flexible services, exempt from the Act. He also suggests consideration to allow mainstream Aboriginal services that currently comply with the Act to elect to opt out to comply with the new standards for flexible services rather than the mainstream standards.

30. Regarding support for staff, the report lists a number of measures envisaged by the Department and supported in consultations including:
    • a menu of support for services;
    • support being normative, not crisis-driven;
    • support should be actively promoted, not passively implemented; and
    • support to be provided through a broker.
31. Regarding governance, management and organisational development, the consultant notes that aged care services are 'complex community functions'. Issues raised in his consultations include:
    • service rationalisation;
    • on call support expertise;
    • peak body support;
    • that a 'catch-all' solution to the frequently identified governance issues was unlikely to be an appropriate response.

Development of Quality in the Flexible Programs

32. In 2006, the Department conducted a workshop for indigenous aged care program managers during which they identified the need to improve quality. There was also a ministerial request to address this issue. During this time, the Department also commenced work on a quality framework, service provider guidelines, program management, service activity reporting and accountability.

33. The quality framework:
    • aligned with community care quality reporting; and
    • used a program management tool developed by the Northern Territory as one of the foundations for its work.
34. The 2006 workshop noted that the flexible services had not previously been required to meet specific quality requirements.
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35. Activity in 2008 included:
    • the third workshop for program managers;
    • those who had used the quality framework reported it resulted in much higher standards of care delivery; and
    • the workshop noted that until the development of the quality framework there had been a vacuum of nationally agreed program management material.

Quality Principles (ie Standards)

36. The Griew report of 2008 indicated providers of flexible services expressed the need to have explicit quality requirements against which they can be assessed. The Quality Principles document lists 24 principles under the four domains of: governance, management and accountability; care services; care recipient rights and responsibilities; and community engagement, networking and innovation.

'Next steps for quality in the flexible program'

37. This section notes 'while the mainstream program under the Act has continued to develop rapidly since the introduction of the Act, there had been few developments for the flexible program – despite numerous attempts by staff… secure extra funding and a focus on the program'.

38. This memo also states that 'prior to the 2006 budget which provided an additional 150 places, the flexible program had not grown for many years'. This is at odds with reports from the 2003 workshop that the number of care places in flexible services had grown from 27 in 1996 to 485 in 2002. It is unclear whether growth occurred from 2002 to 2006, but it would be reasonable to assume that it did.


39. The subject of Aboriginal aged care is important and the challenges are complex. As you have requested, I report to you as a matter of urgency. Much more time could have been devoted to this report. The audit of the flexible services and the development of a quality framework in the Flexible Aboriginal Aged Care Services, that you have recently announced, will facilitate a more comprehensive assessment.

40. Given the terms of reference, the investigation was broken down into three core areas: the Department's handling of the Docker River Flexible Aboriginal Aged Care Service, the Department's handling of complaints regarding the Service since 2005, and the Department's handling of the death of the Elder.


41. During the course of my investigation, I interviewed staff of the Service, staff of the Macdonnell Shire Council, departmental staff in the Northern Territory, departmental staff in Canberra and Ms Kavanagh. I also met briefly with Mr Kevin Brumby and his family. We were unable to make contact with the Honourable W Snowden MP. More than 1500 pages of documentation were examined, including the Coroner's report on the death of the Elder, complaints lodged about the Service, departmental files on the Service, as well as departmental policy documents and discussion papers.
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42. I visited the Docker River Community on 30 September 2008 and 1 October 2008. I visited the Service on the morning of 1 October 2008 from 10:00am to 12:30pm. During that time, I was taken on a tour of the Service and spoke to staff and residents.

Physical environment

43. The Kaltukatjara community is an extremely remote community in the Northern Territory, approximately 670 kilometres south west of Alice Springs and 8 kilometres east of the Western Australia border. It is only accessible via 4WD or chartered aircraft. It is a remote Aboriginal community which is the home of the Pitjantjatjara Aboriginal people. As a consequence of its remoteness, there is limited infrastructure in terms of accessibility of goods and services and the provision of utilities such as rubbish collection and housing. I was advised a Medical Officer is scheduled to visit the community clinic every three months, but had not done so for six months prior to my visit. The Community Clinic Registered Nurse undertakes clinical assessments and seeks advice from Alice Springs if needed. The Service provides residential and community aged care services for clients in the cross-border region of South Australia, Western Australia and the Northern Territory. It is funded for 30 places in a combination of high, low and community based care. The Service is comprised of multiple ground level buildings.

44. The Service is enclosed in a wire fence which prevents the many dogs prevalent in the community from entering the facility. The residential area of the Service is separated from the food preparation area which is in another building. The brick-paved verandas along the front of the rooms have fire pits built into them at regular intervals. The pits, when not in use, are covered by wire grates. On the day of my visit, I observed two fire pits in use, one in which a large log was being burnt and another where a fire was burning which was of lesser intensity. In both instances the grates had been removed from the fire pit. The smoke from the fires was blowing into resident's rooms.

45. I observed two multi-resident rooms during my visit. In one room, there were three beds on a concrete floor. None of the beds had linen on the bare mattresses. The walls ofthis room were stained with grime. There were food preparation facilities within the room, but storage was limited and poorly organised. There were no hand washing facilities in the immediate vicinity of the rooms. To wash my hands, I was required to walk to the kitchen/dining section of the facility and wash my hands in a sink which is also used as a dish washing sink. The second room contained a sick elderly Aboriginal woman. She was being cared for in bed as she was unable to sit up or mobilise on her own.

46. I was shown the laundry facilities which comprised one industrial clothes washer and one industrial clothes dryer. Both were reported as faulty. Some of the clients' clothes were labelled and in locked cages in this room which was only accessible to staff of the Service.
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47. The kitchen was reportedly newly refurbished. It was clean, well ordered and uncluttered.

48. I was shown a veranda fire pit on a disused section of the Service at the rear of the complex. It is unclear whether it was this veranda fire pit or an open fire pit at which the Elder caught alight. I was shown the rear of the complex and the path the Elder took once alight and where she was smothered by the youth worker visiting the service, in his efforts to extinguish the flames.

The Department's Handling of the Docker River Service

Quality Management

49. As can be seen from the policy background to the flexible services, the intention of the Strategy was to provide flexibility of services not thought to be achievable should the services fall under the Act. This resulted in an arrangement where the compliance framework for the services occurred through the funding agreement between the Department and the Service.

50. Throughout the course of this investigation, officers of the Department, in both the Northern Territory and Canberra, referred to the Service either as a flexible aged care service containing residents or clients, or as a supported residential accommodation service containing tenants. In addition, there is a tension between a pure contract management model, in the context of a purchaser/provider environment (ie that the Department purchases services through a provider who provides them and should not 'interfere' with the way in which the provider conducts its business) and a service development model, where departmental officers actively work with the service providers to improve quality.

51. The latter view is influenced by the realities of the remoteness of the Service and the challenges it faced. The contract management approach maintains a separation between the role of the funder and the performance of the provider. History shows, however, that such an approach is limited in developing capacity and quality at the Docker River Service. It also ignores statements in the original policy documents that state that the new flexible services would need management support.

52. A contract management approach is appropriate for a funder to use where a mature environment exists; one that supports the capacity of the organisations to deliver the services they are funded to provide. Such an enabling environment does not exist for the Docker River Flexible Aboriginal Aged Care Service. As part of progressing toward a more enabled, stable capacity and environment, community development support is required. As Griew states, aged care services are 'complex community functions'. Regardless of the management model, the Department should fund a capacity-building and community development support role for the flexible services.
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53. Further, a highly regulated environment exists for mainstream aged care services for which the Commonwealth has direct responsibility. The Commonwealth funds this regulatory framework to ensure quality of service delivery, including funding and managing the Complaints Investigation Scheme (the Scheme) and funding the Aged Care Standards and Accreditation Agency (the Agency). There is no regulatory framework or indeed funding to support such a framework for the flexible services. While I acknowledge the Flexible Aboriginal Aged Care Services exist outside the Act, the failure to develop, fund and support a regulatory framework for the Service over the 13 years of its operation has come at a cost to the quality of the service being provided and to those it was designed to assist.


54. My assessment of the files and interviews with Northern Territory staff indicates there was a sustained and significant amount of work carried out to bring about quality outcomes for residents and recipients of community care services at the Docker River Service. However, the lack of legislative controls and quality mechanisms meant the efforts of staff were often ineffective in improving quality outcomes.

55. A compulsory regulatory framework for mainstream aged care services in Australia was enshrined in legislation in 1997. An independent review of the impact of this new legislative and regulatory framework found it has had a positive impact on quality in residential aged care. Significant expenditure was – and still is – made on quality and compliance mechanisms through the activities of bodies such as the Office of Aged Care Quality and Compliance and the Agency. No such legislation, regulation or expenditure supports quality outcomes in the flexible aboriginal services. The Department made repeated recommendations regarding the introduction of a quality framework for the Flexible Aboriginal Aged Care Services but did not act on them until 2006 when it commenced work on a quality framework and accountability measures. In 2008, these as yet incomplete measures are being trialled in only a few of the flexible services.

56. A reading of the files indicates a series of recurrent failings in quality at the Docker River Service. This included over-medication, under-medication, violence against staff and residents by community members, and residents suffering infectious conditions due to presence of dogs and dog faeces in the rooms and grounds of the facility, with up to 40 dogs living in the facility.

57. The Department's capacity to manage this Service was extremely limited given the lack of legislative controls and a quality framework. This has been acknowledged in departmental forums and documents for years. The failure to develop and evolve this avant-garde program to provide it with protective mechanisms and program support to ensure consistent quality, despite repeated commitments from departmental forums to do so, is unacceptable.
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58. This is now being addressed. The announcement you have made regarding the introduction of a quality framework and support programs for these services is welcome. The Docker River Service is in dire need of an appropriate quality framework against which it can benchmark, and against which the Department can hold it accountable for the funding it receives. It is also in dire need of a program of support to enable it to consistently deliver a culturally appropriate, quality service to its care recipients.

Financial Management

59. In the initial suite of documents provided by the Department, financial reports were not included. Subsequently, we obtained some quarterly reports. During the following timeframes, quarterly reports were received for the Docker River Service: July–December 2006; and April 2007–March 2008. We did not receive quarterly financial reports in the following timeframes: July 2005–June 2006; January 2007–March 2007; and January 2008–September 2008. Of the yearly financial reports, only once was supplied (January–June 2006). The 2005/2006 Funding Agreement required an audited certificate of funds usage. These were received July 2005–June 2006 (not audited), July 2005–March 2006, and July 2006–June 2007 (audited acquittal only).

60. Throughout the documents provided to us, the accounting service undertaking the financial reporting to the Department on behalf of the Docker River Service frequently asked for extensions on the reporting deadlines because they had been unable to obtain the information from the Service.


61. Significant gaps exist in the financial accountability structures managed by the Department. There was recognition by departmental staff that obtaining adequate financial reports from the Service was extremely difficult and because no adequate accountability framework exists, there was little capacity for sanctioning poor reporting except by way of withdrawal of funds.

Service Activity

62. This section of the report is closely linked to the previous quality management section because the way the activity of the Service is measured should provide data on the quality of the services being provided.

63. In August 2005, in part due to complaints received about the Service, a review of the Service against the three Service Objectives of Schedule A of the Flexible Service Funding Agreement 2004/2005 was conducted by officers of the Department. The review report made a total of 53 recommendations ranging to include compliance with the law, the range of services, the quality of those services and the cost effectiveness of the services provided. The report included an Action Plan at section 5 which outlined the recommendations, actions, timeframe and date the action should be completed. This Action Plan has been used by the Service as a template against which the service activity is reported in addition to the proforma service activity report used by all Flexible Aboriginal Aged Care Services.
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64. The Service Activity Reports form part of the reporting mechanisms under the National Aboriginal and Torres Strait Islander Aged Care Strategy and are provided by the Service every six months. All reports have been received from the Service from July 2005 to the present except for the July 2007–December 2007 report.


65. While the Department has received reports from the Service on a regular basis, the data collected provides little information that addresses the quality of the services being provided. The Service Activity Report largely captures quantitative information such as the existence of care plans, for example, but it does not go to the quality of those care plans.


66. Throughout the life of the Service, staffing has been a significant issue and continues to be so. During one 12-month period, there was a turnover of 40 staff. At the time of my visit to the Service, the longest serving clinical staff member had been employed for six months. There was a new Care Coordinator who had only been employed for a matter of weeks, and a new carer for the same period, who came to work at Docker River during her long service leave. The difficulty in recruiting staff to the Service has had a flow on effect, one of which is a lack of coverage overnight at the Service. I understand the Shire is focussing on this overnight issue as a matter of priority. The Department advises that overnight staffing had commenced on 22 September. However, at the time of my visit on the 30th October the appointed staff member for this task had not commenced work.

67. There is evidence in the file that staffing, notably retention of staff, was a particular concern for the Department. Most recently, the Department had arranged for agency staff to fill the shortfall.

68. I was advised that no relationship exists between the service provider and a professional body, so the Service has no way of receiving professional or peer support. In addition, the remote location limits training opportunities for staff and, even if they could attend training, the shortfall in staff further limits the capacity of staff being able to attend. During my visit, I suggested the Service enrol with the Aged Care Channel as a means of encouraging ongoing professional development.

69. In part, the difficulty in staffing is also affected by the lack of dedicated staff accommodation. Currently, staff of the Service reside in shared accommodation with other staff. This means that individual staff members have no respite from colleagues.


70. The high staff turnover, the lack of an adequate number of appropriately skilled staff, the lack of staff support, and inadequate accommodation, have all contributed to the staffing difficulties experienced by the Service. The file demonstrates the Department was aware of those difficulties and tried to work with the Service to address them. However, the Department did not or could not effectively address the underlying causes contributing to the staff turnover.Top of page

Capital Works

71. During the course of the last three years, significant capital works funding has been provided to the Service. This has enabled the repair of the walkways throughout the Service, the building of a security fence around the Service and the building of a kitchen and dining room area as an adjunct to the Service. Approval was given on 12 October 2007 for the utilisation of funds for a camp fire burn protection solution for the open fire pits in the grounds of the facility. At the time of my visit, those protection systems had not been implemented.


72. As can be noted from the physical description of the Service above, significant capital works continue to be necessary. This needs to be overseen by the Department, having undertaken a risk and capital assessment of the Service.

General Findings

73. Recommendations to incorporate the Flexible Aboriginal Aged Care Services under the Act were made as early as 2003, but were not pursued by the Department. Incorporation of the services under the Act, with appropriate standards, would provide a regulatory framework and create the capacity to adequately monitor the quality in the services.

74. During 2007, the Department trialled an as yet incomplete quality framework in eight of the Flexible Aboriginal Aged Care Services. A 2008 workshop reported that the quality framework had been embraced by indigenous aged care providers. This work continues and is a welcome course of action.

The Department's handling of complaints regarding the Docker River service

75. The scope of my investigation is limited to the complaints received by the Department from the time Ms Kavanagh made her complaint in May 2005 to the present. In total, there were complaints from three individuals during this period.

76. The Department sought to address the concerns raised by Ms Kavanagh. However, it was limited in its capacity to act because the Service sits outside the Act, restricting both the Department's scope to sanction and/or use existing complaints mechanisms such as the Scheme.

77. In response to the issues raised in Ms Kavanagh's complaint, significant activity occurred between the management of the Service and the Department, culminating in a site visit on 21 June 2005. On the same day, Ms Kavanagh complained in writing to the Honourable W Snowden MP, who responded on 14 July 2005. Further activity between the Department and the management of the Service occurred, and a letter of 15 July 2005 from the Department demanded immediate attention be given to a range of issues. A review of the Service was undertaken in August 2005. The Department appears not to have provided any feedback to Ms Kavanagh on its activity in response to her complaint.
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78. The second complaint was made by a staff member from NPYWC on 15 June 2005. She expressed concern about the state of the building and occupational health and safety concerns. She stated she was concerned residents of the Service had been admitted to hospital with illnesses attributed to dogs and dog faeces and expressed concern about the governance arrangements impacting on the Service.

79. Following internal consultation, the Department responded to this complainant, thanking her for her email and indicating the Department was aware of the situation at the Service.

80. Most recently, on 6 August 2008, a case was created under the Investigation Management System of the Scheme in relation to an anonymous complaint about the number of clients residing in the Service, staff not being rostered on at night and that the fence was locked at night. The investigator called the Service and spoke to staff who confirmed all of the issues, and indicated there was a call bell system overnight that would alert staff should it be necessary, that the fence also locked staff in so it was not perceived as a problem, and that a senior manager would be commencing work in the next week. Given the lack of legislative cover for the Service, it is not clear why the Scheme was handling the matter.


81. Without a regulatory framework and in particular the capacity to sanction, any response to complaints by the Department was frustrated and limited. Despite much activity following the complaint of Ms Kavanagh, including the development of a reporting document for the Service, the outcomes would not have addressed her concerns.

The Department's Handling of the Death of The Elder

82. The Department was notified of the death of the Elder on 15 June 2007 by telephone from the Council Clerk in Docker River. The intradepartmental email of that date states that the fire pits on the veranda had been covered in and not in use and that the fire in question was in an open area away from the facility.

83. This account conflicts with the Shire Services Manager's identification of the fire at which the Elder caught alight. He indicated it was one of the veranda fire pits. The Coroner concluded it was not clear which fire pit had been the one at which the Elder caught alight. The veranda fire pits were still in use at the time of my visit. The grates on these fire pits had been removed.

84. On 18 June 2007, Mr B Watts, the Chief Executive Officer of the Council asked the Department to conduct a risk assessment of the Service. Departmental staff undertook a site visit of the Service and an intradepartmental email indicates a risk assessment was undertaken.

85. Approval was given to undertake capital works on fire protection systems on 12 October 2007 and a letter of offer was sent to the President of the Community Council on 27 October 2007. A Deed of Variation was signed by the Department on 28 November 2007.


86. The Coroner found that the risk to the Elder from the fire pits at the Service was high and predictable. At the time of my visit, the veranda fire pits were still in use and the burn protection devices for the open fire pits in the grounds of the facility remained unimplemented. The Department had been aware the fire pits were an issue the day after the Elder died and yet over 12 months elapsed before the burn protection devices were finally installed. As I finalise this report I am advised that the burn protection devices have been installed and the veranda fire pits have been filled in during the course of this investigation.


The Department's handling of the Service

87. These recommendations are made acknowledging, and in the context of, the Ministerial direction for an audit of all indigenous flexible aged care services, of the commitment to implement a quality framework, and a range of other support initiatives in the flexible services. The following specific recommendations are made:

88. The Department should undertake a formal review of the Aboriginal and Torres Strait Islander Aged Care Strategy in the next six months.

89. The review of the Strategy should clarify the relationship between the Department and the Flexible Aboriginal Aged Care Services, addressing the nature of the service, the provision of capacity-building support , and the nature of the clients of the service.

90. The Minister should establish an Aboriginal and Torres Strait Islander Aged Care Advisory body in the next six months. This body should: provide the Department with advice and information on building capacity and improving quality in indigenous aged care services; provide the opportunity to share evidence, experience and initiatives; and be a forum for peer leadership. Membership should be made up of individuals chosen for their experience and expertise in indigenous aged care.

91. The Aged Care Act and its Principles should be amended in the next 12 months to enable the 30 Flexible Aboriginal Aged Care Services to fall within its jurisdiction under a new section titled Flexible Indigenous Aged Care Services. The new legislation should maintain the original objectives of the flexible services in order to allow older indigenous people to age and die in country, and to allow for flexible and culturally appropriate services to be delivered by the services. Further, I do not support the recommendation by Griew that services ought to be able to opt out of the jurisdiction of the Act, particularly where they already comply.

92. The Department should fund a program of roving quality managers to visit all of the flexible services in the next three months with the objective of making support normative. The program would also have the objectives of building capacity locally by developing administrative systems, documentation, providing education and training, and advising on governance. A model similar to the Northern Territory Emergency Response income management support program could be considered, where officers stay in each location for a week at a time, with the support provided assessed on a case-by-case basis. The program should have a regular timetable for the routine visits, with frequency decreasing over time.

93. In developing quality standards, the Department notes Aboriginal flexible aged care providers' requests for a peer assessment model, and that they do not want a process with a 'paperwork orientation'.

94. As part of the quality framework development, consideration should be given to the introduction of appropriate financial controls against which the Department can ensure the funding provided to the Flexible Aboriginal Aged Care Services is used appropriately.

95. The Department should develop a service activity reporting structure which captures the quality, quantity, timeliness and cost of activity in the Service.

96. The quality framework under development by the Department should include a framework for training and development.

97. The Department should make available funding for the maintenance and/or upgrading of the rooms in the Docker River Service to include adequate floor and wall covering and hand washing facilities as a priority. The Department should undertake an assessment of the capital works needs at the Service and develop a timetable for the roll out of sufficient funds and activity to address other deficiencies identified.

98. Appropriate accommodation should be made available for staff in the flexible aged care services. I note your recent commitment to provide $800,000 for staff accommodation at the Docker River Service.

99. The Department should monitor and ensure an adequate number of appropriately skilled staff in the Service, including overnight.

Complaint handling

100. A complaint handling framework should be included in the review of the quality framework

101. In amending the Act and its Principles scope for the Department to monitor and manage complaints about the Service should be provided.

Response to the death of the Elder

102. The Department should monitor the safe use of fires at the Service.


103. As stated at the outset of this report, the policy and program approach in implementing the flexible services was necessarily and appropriately avant-garde. However, it involved inherent risks that would need to be closely monitored and managed. The same remains true. Given the history of recommendations regarding the Aboriginal Flexible Aged Care Services, the Minister should consider commissioning an external, independent review of the Services, including the implementation of any recommendations accepted from this report and the other initiatives announced recently, in a time deemed appropriate but no later than three years.


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