Inquest into the death of Alex Raichman

Contributing factors

• Unsecured en suite window in bedroom 2
• Low perimeter fence allowing escape
• Inadequate staffing levels; 1:1 care not provided as contracted
• Failure to implement known safety measures (window locks, fence height)
• Budget constraints prioritized over safety
• Poor organizational communication about hazards and risk
• Failure to escalate safety concerns from staff
• Incomplete emergency repairs after near-miss escape on 20 April

Coroner's recommendations

1. Office of the Children's Guardian should consider amending the definition of 'substitute residential care' (SRC) to capture entities providing respite care for more than one night in any 7-day period.
2. Office of the Children's Guardian should take steps to ensure that Civic does not provide SRC or SSRC to persons under the age of 16 years.
3. Office of the Children's Guardian should, in circumstances where Civic seeks to be authorised for Statutory Out of Home Care as a designated agency, consider any findings of this inquest and any deficiencies in Civic's provision of past VOOHC when making that decision.
4. Office of the Children's Guardian should provide to the appropriate Minister a copy of the findings of this inquest.
5. Civic Disability Services should agree to a restriction that it does not provide SRC or SSRC to children and young persons under the age of 16 years.
6. Civic Disability Services should devise and roll out a training program for staff addressing the processes available for alerting all levels of management in Civic of risks within the Civic environment, including direct contact with the CEO.