Finding into death of Leslie Roberts

Contributing factors

• Failure to conduct timely welfare check when client unresponsive to phone and door contact
• Inadequate backup coverage when primary carer absent on sick leave
• Assumption that client was out rather than triggering concern
• Delay in discovering fall and initiating emergency response
• Prolonged time on ground in hypothermic conditions before discovery

Coroner's recommendations

1. Implement mandatory welfare check protocols when vulnerable clients with established routines fail to respond to contact at expected appointment times
2. Establish clear escalation procedures requiring contact with Victoria Police or Ambulance Victoria when direct contact attempts fail for clients known to be home at scheduled times
3. Develop adequate backup staffing arrangements in disability services to ensure continuity of care for vulnerable clients, particularly in rural areas with limited resources
4. Provide training to supervisory staff on recognising welfare risk indicators and appropriate escalation thresholds for clients with intellectual disability living independently