Coroner's Finding: NISCO Sophia Alessia

Contributing factors

• inadequate supervision and observation of a high-risk child
• child left unattended in playroom while carers attended to another child
• insufficient staffing at facility during shift changeover (3:30-4:00pm gap)
• disposable gloves accessible in multiple locations (bathroom vanity, bins, dispensers)
• inadequate care plan documentation of risk factors
• incomplete communication to all staff of child's oral fixation behaviours
• child's well-known propensity to place objects in mouth not integrated into environmental safety measures

Coroner's recommendations

1. disAbility Living should revise procedures for preparation of care plans to include comprehensive documentation of characteristic behaviours, specific risks, and risk management strategies with prominent display on first page
2. Care plans should address the level of supervision and observation required for individual clients
3. All staff should sign care plans with declaration they have been read; same should apply to revised versions
4. Management and carers in facilities should have access to clients' medical history
5. A comprehensive functional needs assessment should be undertaken for all individual clients prior to placement in institutions or respite facilities
6. Medical examination and assessment should be made available to management and staff of respite facilities regardless of state care status
7. A dedicated 'key worker' should be assigned to each individual child in institutions and respite facilities responsible for oversight of care, education of other carers, reception and recording of information relating to needs and safety, and upkeep of documentation
8. Identification of risk and means of risk management should be prominently displayed on first page of all care plans