Inquest into the death of Pono Wairua Aperahama

Contributing factors

• Inadequate behaviour support plan guidance for community outings, particularly pool visits
• Delayed and incomplete finalisation of pool risk assessment
• Lack of consistent carer—less familiar carer (Mr Bender) permitted high-risk activity
• Inadequate training of returning carer on current behaviour support strategies
• Poorly coordinated transition planning from child to adult services
• Staff uncertainty about employment continuity leading to staff turnover
• School exclusion resulting in unstructured time and reduced routine
• Physical and psychological stress from restraint escalating cardiac dysrhythmia

Coroner's recommendations

1. Challenge Community Services should consider whether all guidance relating to a person in their care be contained in a single Behaviour Support Plan rather than separate documents
2. Challenge Community Services should review the Behaviour Support Plan policy to include appropriate methods for distributing plans and guidance to carers, including expectations on carers to access and review such guidance
3. Challenge Community Services should review the Behaviour Support Plan policy to include appropriate methods for training a carer on a client's current behaviour support needs when that carer is not regularly involved in the client's care
4. Challenge Community Services should consider providing specific disability training to all carers of clients with an intellectual disability, particularly regarding the needs and capacity of such clients and appropriate forms of communication
5. Challenge Community Services should consider developing a policy regarding the process by which clients leave residential care or transition from child to adult services to ensure this process is undertaken at the earliest opportunity with sufficient time to ensure planned and smooth transition
6. Department of Communities and Justice should consider, as part of state-wide review of Complex Care Review Panels, whether there are adequate mechanisms for oversight of residential out-of-home care placements, including adequacy of behaviour support, review of risk of significant harm reports, and adequacy and implementation of leaving care plans
7. Department of Communities and Justice should consider revising behaviour support policy with respect to children with cognitive impairment to achieve harmony with behaviour support policy adopted under the National Disability Insurance Scheme
8. Department of Communities and Justice should consider recommending that all guidance should be contained in a single Behaviour Support Plan rather than separate documents
9. NSW Police Force should consider the evidence and findings as part of current review of NSW Police Force policy and guidance relating to positional asphyxia and related causes of death during restraint
10. NSW Police Force should consider whether guidance should be amended regarding the description of possible causes and risk factors involved in sudden death during restraint
11. NSW Police Force should consider whether further guidance can be given to officers involved in restraint regarding circumstances where restraint should be modified or ceased
12. NSW Police Force should consider whether further guidance can be given to officers involved in restraint to better assist them to recognise warning signs that a person's condition is deteriorating