3. Mistreatment and Associated Reporting Mechanisms

Overview

3.1
Residents, family members and staff of aged care facilities raised concerns that mistreatment is occurring in residential aged care facilities, and questioned whether the true rate of mistreatment was known. Strong concerns were expressed regarding the handling of medication, wound care, pain management, incontinence management, nutrition and the general standard of care.
3.2
Additionally, concerns were raised that the associated reporting mechanisms for mistreatment in residential aged care are not functioning adequately. Family members and carers of residents of aged care facilities, as well as staff, described their experiences navigating the complaints process, with some citing a fear of reprisal and lengthy process resolution timeframes.
3.3
A number of inquiry participants stated that they had witnessed or suspected mistreatment. As noted on the Committee’s inquiry webpage, the Committee is not able to investigate individual cases. Nevertheless, the information provided a valuable insight into the lived experience of some families, resident representatives and staff of residential aged care facilities.

Instances of Mistreatment

Definition of Mistreatment

3.4
The mistreatment of older persons is often referred to as a form of ‘elder abuse’. The Australian Government’s My Aged Care website sets out that elder abuse can be ‘physical, psychological or emotional, sexual or financial’. Mistreatment ‘can also be the result of intentional or unintentional neglect’.1
3.5
Inquiry participants referred to the definition of elder abuse from the World Health Organization (WHO).2 This definition encompasses:
A single or repeated act;
A lack of appropriate action;
Direct or indirect abuse;
Financial abuse;
Physical abuse;
Psychological abuse; and
Sexual abuse.3
3.6
The Australian College of Nursing suggested that the definition of mistreatment should include physical, mental and language issues, and stated that ‘that there is a critical difference between deliberate mistreatment and neglect’.4
3.7
Mistreatment was defined by the Australian Physiotherapy Association as ‘not only noteworthy abuse but, equally importantly, neglect and a lack of appropriate action’.5
3.8
The Vintage Reds of the Canberra Region described different forms of mistreatment as deliberate, accidental and systemic mistreatment.6
3.9
The Townsville Community Legal Service (TCLS) expressed the view that abuse occurring within a residential aged care facility should be referred to as ‘institutional elder abuse’. Although there is ‘no accepted, authoritative definition of institutional abuse of older persons’, the TCLS stated that institutional abuse ‘is often described as mistreatment or maltreatment or abuse of a person by or from a system of power’.7 The TCLS stated that institutional abuse may occur in three ways:
Overt abuse, which might include financial, physical, sexual or emotional abuse;
Program abuse, which may occur when the institution itself operates below acceptable conditions or through improper use of its power; and
Systems abuse, in which an entire care system might cause mistreatment through inadequate resourcing.8
3.10
The Aged Care Complaints Commissioner (Complaints Commissioner) stated that the WHO definition of elder abuse is ‘a significantly broader definition than the current requirements’ in the Aged Care Act 1997 (Aged Care Act) for mandatory reporting by aged care services. The Complaints Commissioner further stated that the Aged Care Act’s ‘narrow definition’ of abuse for the purposes of mandatory reporting does not include much of what would be considered elder abuse by the WHO.9

How Can Mistreatment Occur?

3.11
Mistreatment of residents in aged care facilities can occur through the actions of staff, other residents, or family members or carers. The Australian College of Nursing stated the ‘overwhelming view [is] that different forms of mistreatment do occur’ in residential aged care facilities.10
3.12
Anglicare Australia stated that although the incidence of mistreatment was low, every incident warranted scrutiny. Anglicare Australia stated that these incidences ‘could be a result of poor procedures, an unhealthy culture, individual incompetence or a combination of these factors’.11
3.13
Leading Age Services Australia (LASA) asserted that ‘when systemic mistreatment in residential aged care facilities happens, it is almost always accompanied by a breakdown in leadership and organisational culture’.12 The LASA suggested that instances of mistreatment occur ‘by exception’, and can be managed at the provider level:
Mistreatment is prevented and addressed early through mandatory staff training, having multiple options for people to speak up and make complaints, and ensuring families, residents and staff are not punished for speaking up.13
3.14
The Vintage Reds of the Canberra Region stated that accidental mistreatment was ‘highly likely’ to occur when staff numbers or skills were lacking, and that:
It is especially likely to occur when staff are dealing with a high workload, very demanding clientele with competing demands, where staff are working extra shifts, where there is high turnover of staff and where communication between staff or between staff and residents is compromised in some way.14
3.15
A link between insufficient staffing numbers and low-quality care was also raised by the New South Wales Nurses and Midwives’ Association (NSW NMA), which stated that the majority of nurses it surveyed ‘reported that insufficient numbers of staff on duty was a causal factor in the incidence of abuse’.15
3.16
The Australian Medical Association (AMA) stated that low-quality care was occurring due to health issues of residents not being attended to in an efficient manner:
Many of the reports of low-quality care we have seen in the media recently are usually as a result of health issues that could have been rectified by timely medical attention; however, residential aged-care facilities are moving away from employing registered nurses, and medical practitioners are not well supported to provide the services they want to their older people outside their own practice.16
3.17
New Aged Care stated that a number of its General Practitioners (GPs) had reported observed mistreatment in residential aged care, including:
Pressure on GPs to prescribe medication inappropriately;
Residents being transferred to hospitals unnecessarily;
A witnessed incident in which a carer slapped a resident, and no visible follow up by agencies;
A rise in the number of errors in the provision of medication;
The perception of a ‘backlash’ when deaths are reported to a coroner; and
Alteration of a resident’s notes which documented concerns over care.17
3.18
An example was given by New Aged Care of pressure to prescribe antipsychotic medication to a resident without any clinical needs or indications, because the resident was wandering into rooms, yelling, did not sleep through the night, and was trying to leave the premises while there was inadequate staffing to manage the situation.18
3.19
Estia Health advised that, as a provider of aged care services, it found the role of family members in abuse to be ‘complex’, stating that:
… while many reviews have focussed on staff and fellow residents as the abuser, there has been little study into the role of the family members of the resident, particularly in regard to financial and psychological abuse.19
3.20
The LASA described possible abuse of residents by family members, and stated that residents had returned from leave with family members with signs of mistreatment. The LASA also stated that financial abuse of residents by family members can occur.20
3.21
The Office of the Public Guardian Queensland (OPG Queensland) stated that aged care facilities had contacted the agency to report suspected financial elder abuse when a resident’s residential aged care fees had fallen into arrears. The OPG Queensland further stated that when financial abuse had been investigated, it had found ‘other very frightful forms of abuse as well that are not financial’.21

Data on the Prevalence of Mistreatment

3.22
The Complaints Commissioner stated that ‘on current information it is not possible to say how often residents in aged care facilities are mistreated or abused’.22
3.23
Similarly, Professor Joseph Ibrahim stated that ‘there is no doubt that mistreatment occurs in residential aged care’.23 Professor Ibrahim also stated that ‘mistreatment is easily hidden’ for a number of reasons, such as the misdiagnosis of mistreatment as the ageing process, an inability or reluctance to complain, limited available data on mistreatment, and narrow definitions of mistreatment.24
3.24
Speech Pathology Australia also stated that it can be difficult to differentiate between the effects of neglect and the effect of chronic disease in older people.25
3.25
Catholic Health Australia stated that the number and level of complaints made to the Complaints Commissioner is the ‘primary proxy measure used to gauge the extent of mistreatment’. Catholic Health Australia measured the number of complaints against the number of days of care (67.2 million days of care provided to nearly 240 000 people), describing the incidence of mistreatment as ‘low, but not low enough’.26
3.26
The inability to calculate the true prevalence of mistreatment in aged care facilities was highlighted by a number of inquiry participants.27 The Combined Pensioners and Superannuants Association of NSW (CPSA) stated that the statistics publicly reported by the Department of Health contain only reportable assaults, and ‘where the same perpetrator assaults the same victim multiple times these multiple assaults are reported as a single assault’. The CPSA stated that ‘it is therefore fair to say that the published data [does] not accurately represent the true horror of the incidence of physical and sexual assault in residential aged care in Australia’.28
3.27
A number of inquiry participants drew attention to the work of the Health Law and Ageing Research Unit (HLARU) at Monash University.29 The HLARU’s research program has focussed on preventable deaths and reducing the risk of fatal injury in residential aged care facilities.30 Professor Ibrahim, a leader of the HLARU team, stated that the team’s work has been limited by the lack of data available:
Our research team’s work into premature deaths is a ‘tip of the iceberg’ phenomenon. Describing the quality of care delivered, let alone any trends, in [residential aged care services] in Australia is hampered by lack of readily available, standardised, objective, national level measures for quality of care that is accessible to researchers.31
3.28
Professor Ibrahim outlined that there was no available data on serious permanent injury, minor temporary injury or abuse of individual rights and choice. Data is collected on the number of unexplained absences of residents, but Professor Ibrahim questioned the utility of the collection of this data, which is not made available to the public. 32
3.29
Mr David Gavin stated that he and a group of family members of residents of a particular aged care facility have recorded observed incidents over a twelve month period, grouped into: clinical, wound care, hygiene, food, communication issues and staff. In total, 55 incidents of mistreatment were observed by the group, for a facility with 120 residents.33
3.30
The Department of Health advised that of the ‘239 379 people receiving permanent residential care in 2016-2017, the incidence of reports of suspected or alleged assaults was 1.2 per cent’.34

Publication of Key Indicators

3.31
The National Aged Care Quality Indicator Program (the Program) is a voluntary program for aged care services coordinated by the Department of Health. Quality indicators are measured to ‘give consumers transparent, comparable information about quality in aged care to aid decision making’ and for ‘providers to have robust, valid data to measure and monitor their performance’.35
3.32
The three clinical indicators measured for the Program are pressure injuries, use of physical restraint and unplanned weight loss.36 Data from the Program will be published on the My Aged Care website when it has been ‘established as reliable and accurate and following stakeholder consultation’.37
3.33
Professor Ibrahim found that 15.2 per cent (3289) of aged care deaths reported to coroners over a 13 year period were ‘from external or preventable causes, almost all unintentional’. Of those unintentional deaths, 81 per cent died from falls, 7.9 per cent died from choking and 1.2 per cent died from complications of clinical care. Of those intentional deaths, 4.4 per cent died from suicide and one per cent died from resident-on-resident assault.38
3.34
Professor Ibrahim recommended that these statistics be linked with various indicators of care, for example, the number of choking deaths should lead to an examination of oral and dental care and complications of aspiration pneumonia, malnutrition, and sepsis.39
3.35
The Program was described as ‘clinically focused’ by Dementia Australia, which stated that the information does not ‘capture consumer experience and quality of life within aged care services’.40
3.36
Key indicators for publication were suggested by inquiry participants as being a useful measure of mistreatment, such as:
Fall rates;41
Injuries including pressure sores;42
Infection rates;43
Staffing and skill mixes;44
Use of restraints;45
Medication errors;46
Transfers and admissions to public hospital from an aged care facility;47 and
Weight loss.48
3.37
Aged Care Crisis stated that, in particular, ‘pressure injuries are one of the important markers of good or bad nursing care and should be assessed to determine whether staffing levels and skills are adequate’, as they are preventable and treatable if detected early.49
3.38
The Australian College of Nursing suggested adding nursing hours per resident day.50
3.39
Mrs Sue Smith recommended other metrics be monitored and published, including:
The budget allocated to meals;
Performance standards for responding to requests for assistance;
Resident and family member satisfaction;
Average life span of residents after admission;
Fees; and
Descriptions of the environment.51

Experiences of Mistreatment

3.40
Observed and suspected instances of mistreatment were put forward by inquiry participants, who outlined a range of issues experienced by residents, their families and staff of residential aged care facilities.
3.41
Dementia Australia stated that although it hears ‘many reports of quality service delivery and support in residential aged care settings, [it] also hears from consumers with far less positive experiences’.52 Dementia Australia particularly highlighted the experiences of people with dementia:
These stories paint a disturbing picture of an aged care system under strain and in many cases ill equipped to support residents with dementia, especially in instances where behavioural and psychological symptoms of dementia (BPSD) may be present.53
3.42
Care Guidance stated that older Australians may be delaying entering residential aged care ‘because they are fearful that they will experience mistreatment’. Older Australians who delay entry to aged care may experience ‘adverse health events that lead to a faster deterioration in health than would perhaps be the case had they accessed residential care earlier’.54

Restrictive Practices

3.43
Restrictive practices include the use of physical and chemical restraint. The use of physical restraint in residential aged care facilities is captured under a voluntary Program.55 Accreditation Standard 2.13 ‘Behavioural management’ assesses the restraint policy and authorisation of aged care facilities, and where restraint is used it has been assessed, authorised and is monitored to ensure safe and appropriate use.56

What Are Restrictive Practices?

3.44
The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) defined restraints as:
Any device, material or equipment attached to or near a person’s body and which cannot be controlled or easily removed by the person, and which deliberately prevents or is intended to prevent a person’s free body movement to a position of choice and/ or a person’s normal access to their body.57
3.45
The Office of the Public Advocate (Queensland) (OPA Queensland) stated that the use of restrictive practices ‘to manage the challenging behaviours of people in the aged and disability sectors has become a key human rights issue in Australia’.58 OPA Queensland defined restrictive practices as:
Detention;
Seclusion;
Restricted access to objects;
Physical;
Chemical; and
Mechanical restraint (as well as electronic forms of restraint such as tracking bracelets, camera surveillance, or restrictions on media devices).59
3.46
The Office of the Public Advocate Victoria (OPA Victoria) stated that it was aware of the use of restraints in residential aged care, including:
… physical restraints in beds, on toilets, in chairs, chemical restraints due to challenging behaviours and wandering behaviours in dementia sufferers, and other limitations on freedom of movement—for example, the use of keypads to, effectively, lock dementia wards.60

Use of Restrictive Practices

3.47
The Department of Health produced the Decision-Making Tool: Supporting a Restraint Free Environment in Residential Aged Care (Decision-Making Tool), which sets out that in a person-centred, restraint-free approach, ‘the use of any restraint must always be the last resort after exhausting all reasonable alternative management options’.61
3.48
The OPA Queensland stated that there is no reference to the Decision-Making Tool in aged care legislation or the Quality of Care Principles. The OPA Queensland stated that although the document is available online, ‘there is no requirement that residential aged care facilities train their staff in these matters to meet legislative or accreditation requirements’.62
3.49
Similarly, the TCLS stated that the absence of regulatory frameworks for the use of restrictive practices is ‘concerning’, as the Aged Care Act ‘does not prohibit, legislate for, or regulate the use of restrictive practices to manage the challenging behaviours of some aged care residents’.63
3.50
The Law Council of Australia stated that ‘there are … serious questions in relation to the degree to which some facilities seek consent for use of chemical restraint’, and recommended a review of the use of restrictive practices.64 The Law Council of Australia further recommended the collection of data on the use of restrictive practices, including the:
Form of restraint applied;
Reasons for use;
Duration of use;
Outcome of the restraint; and
Any adverse events that occurred.65
3.51
The Australian Law Reform Commission (ALRC) recommended the use of restrictive practices be regulated under the Aged Care Act ‘to discourage the use of restrictive practices and set a clear and high standard, so that the practices are subject to proper safeguards and only used when strictly necessary’.66 The ALRC considered that restrictive practices should only be used as a last resort, and only where they would prevent serious physical harm, and their use should be reported to a (new) independent Senior Practitioner for aged care.67
3.52
The Carnell-Paterson Review recommended that restrictive practices be limited to being the ‘least restrictive’ and used only as a last resort. The Carnell-Paterson Review also recommended that providers should record and report the use of restrictive practices, the use of psychotropic agents be assessed by accreditation assessors, and the use of antipsychotic medication to be approved by a Chief Clinical Advisor.68
3.53
The ANZSGM stated that it does not support the use of restraint in acute or long term settings because its use ‘is not supported by evidence of efficacy or safety’. The ANZSGM drew attention to the ‘growing body of evidence regarding the negative consequences of restraint use including physical, psychological and ethical problems’.69
3.54
Further, the ANZSGM stated that use of restraints to manage residents ignores the issues causing the behavioural symptoms:
… if we have a patient or a resident who has severe dementia who wanders all the time, the place to look after them is in a place where he or she can wander all the time—not restrain them in any way. That's where it's so important to match people's needs with what they are provided with—whether it is environment, nursing care et cetera.70
3.55
The ANZSGM stated the view that the use of chemical restraints was changing, with education provided on the use of chemical restraints as a last resort only.71 This was demonstrated by UnitingCare Queensland, which stated that its use of antipsychotic medication within its Memory Support Units decreased by 60.8 per cent from 2015 to 2016. This was achieved through the implementation of a new service model.72

Personal Accounts of Restrictive Practices

3.56
Mrs Margaret Daly described witnessing a number of instances of restraints being used in a facility, stating that vulnerable residents who could not communicate ‘were seated with tables over them preventing them from walking or strapped into wheelchairs with no cushioning to prevent pressure sore[s]’, and described seeing:
A resident ‘strapped into a wheelchair, sometimes in the dark’;
A resident strapped into a wheelchair who slid down ‘nearly choking herself’;
A resident whose room entryway was blocked by ‘a large couch across the door’, leading the resident to pace the room;
A resident being locked in a room containing a chair with a strap ‘ripped to bits’; and
Residents who had previously been seen walking being strapped to chairs after being in the facility for a few weeks.73
3.57
Aged Care Crisis described the use of a physical restraint on a resident with dementia:
She was harnessed into the chair by a piece of cloth tied around her waist to the arms of the chair. One day she wriggled down and was trapped by the cloth around her neck. Had it not been for one of the other residents, she would have choked.74
3.58
One inquiry participant, who did not wish to be named, stated that in one facility, ‘many unfortunate residents are restrained for the entire day and on an ongoing basis. The only time they are unrestrained is for the purpose of using the bathroom’.75 Further, the inquiry participant stated that family members who had consented to the use of restraints for the resident were unaware of the ‘negative effects of using restraints’.76
3.59
G W Hitchen stated that her late mother had been administered a chemical restraint ‘because staff handling my mother failed to take into account she was profoundly deaf and was disturbed by their inappropriate physical handling’, and suggested that staff could have approached her mother using auditory equipment instead.77
3.60
Dementia Australia set out a number of consumer stories about the use of restrictive practices for residents with dementia. These included:
A family member whose husband was tied to a chair after wandering into other residents’ rooms;
A family member whose husband was placed onto antipsychotic medication after wandering into other residents’ rooms, and who was given a higher dosage of antipsychotic medication against the family member’s wishes;
A family member or carer of a resident who was prescribed antipsychotic medication because staff ‘wanted her to be manageable’;
Sedatives being prescribed without the resident or family member’s knowledge and wishes; and
Residents with dementia being sedated and left in front of televisions all day.78

Wound Care and Pain Management

3.61
Clinical care and pain management in aged care facilities are assessed by the Quality Agency under the Accreditation Standards. Wound records and charts are reviewed by the Quality Agency during the assessment process, and education on wound care is assessed.79
3.62
The AMA stated that the Accreditation Standard on clinical care was the second highest outcome not met by aged care facilities in 2016-2017, which ‘shows that aged-care staff are finding it difficult to understand, or are unable to carry out, what is expected of them in terms of clinical care’.80
3.63
Painaustralia stated that ‘up to 80 per cent of people in residential aged care have persistent pain, and evidence suggests [that] pain is often under-treated in the elderly’.81 Untreated or mismanaged pain ‘can perpetuate the pain condition’, as well as lowering quality of life and having an impact on mental health.82 Painaustralia stated that residents with dementia may be under-treated for pain conditions compared with those without dementia, ‘despite similar levels of potentially painful conditions’. Painaustralia further stated that:
In one study, pain was detected in just 31.5 per cent of cognitively impaired residents compared to 61 per cent of cognitively intact residents, despite both having similar incidence of potentially painful conditions.83
3.64
The Australian Pain Society produced the resource Pain in Residential Aged Care Facilities: Management Strategies for use by residential aged care providers, the medical profession and staff of aged care facilities. Painaustralia highlighted the utility of this resource, which provides a guide to ‘what should be happening’ in aged care, but which does not have an implementation or distribution strategy.84 The guide outlines:
How to identify and assess pain in aged care residents;
Alternatives to medication for pain management, including psychological and educational approaches, physical activity and movement, and complementary medicine;
How pharmacological approaches should be undertaken, and what to consider;
Special considerations for residents with cognitive impairments and at end of life;
How to recognise the role of nutrition in pain management, for example, identifying dehydration; and
How the current aged care regulatory framework assesses pain management.85

Personal Accounts of Wound Care and Pain Management

3.65
Ms Goya Dmytryshchak described her father’s experience in a facility, in which a bacterial infection was not investigated and led to blood poisoning:
… if dad’s ongoing complaint of pain was properly investigated by the doctor over the last few weeks, perhaps by a urinary test rather than with paracetamol, this infection would have been detected in the early stages where it could have been simply treated, as in the past, with oral antibiotics.86
3.66
One inquiry participant, who did not wish to be named, described witnessed mistreatment which included: a resident showered with hot water despite having a large ulcer, and two residents whose wounds were not managed and who later died from sepsis. In each case, the participant stated that it appeared that the wounds were not reported or managed according to protocol, and that family members may not have been informed.87
3.67
Similarly, G W Hitchen gave an account of a resident with a severe pressure ulcer, and stated that injuries ‘of this sort do not arise overnight – they are markers of sustained neglect, combined with malnutrition, immobility, poor hygiene, rough handling, maceration [and] infection’.88
3.68
An inquiry participant, who did not wish to be named, described an incident in which a resident had experienced a significant amount of pain due to poor handling by facility staff, and had to be put on a pain management program:
… she was dropped onto her bed which resulted broken ribs and … pneumonia. Her care required two staff to assist with a mechanical aid to get her to bed but because another resident required care one staff member decided to operate the mechanical device alone to ‘save time’. It was very distressing to see mum in pain due to an ‘incident’, which resulted in having a pain management program for three weeks.89
3.69
Another inquiry participant stated that they had sought the services of Wounds Australia, after being concerned that the provider was not managing pressure sores appropriately. The participant stated that ‘without these external services I doubt the family member would have received the appropriate and necessary care by [the] facility’.90

Medication Management

3.70
Medication management in aged care facilities is assessed by the Quality Agency under Accreditation Standard 2.7. The administration and management of medication in residential aged care facilities was the most commonly complained about aspect of care to the Complaints Commissioner in 2017-2018.91
3.71
The Department of Health described the area of medication in residential aged care facilities as ‘complex’, with differences between what can be dispensed by a nurse and a care worker, and with some aspects of medication management regulated by the states.92
3.72
The Guiding principles for medication management in residential aged care facilities, released by the Department of Health in 2012, set out that enrolled nurses (ENs), assistants in nursing and personal care workers may perform medicine-related tasks in accordance with state and territory legislation.93
3.73
The Carnell-Paterson Review drew attention to failures in medication management at the Oakden Older Persons Mental Health Service (Oakden) in South Australia, and recommended that medication management be more effectively addressed during the accreditation process for aged care providers. The Carnell-Paterson Review also recommended that a Resident Medication Management Review be conducted on a resident’s admission to aged care, following any hospitalisation, on the deterioration of a medical condition or behaviour, or any change in medication.94
3.74
The high number of medications taken by aged care recipients, at an average 9.75 medications per resident, was put forward by the Carnell-Paterson Review as an example of the significance of medication management. The Carnell-Paterson Review stated that staff awareness of adverse effects of medication and medication incident reporting were under the control of the provider.95
3.75
The ANZSGM stated that specialists were required to oversee older Australians who may be taking multiple medications ‘because some of these medications are actually causing some of their problems, and removing them makes them better’.96
3.76
Civil Liberties Australia stated that staff training around the delivery of medication is ‘sometimes inadequate’, and that ‘the quality of life for some residents would be diminished by medications not being given correctly’.97
3.77
Members of the medical profession stated that there was a trend towards medication administration being transferred from Registered Nurses (RNs) to care workers. The Queensland Nurses and Midwives’ Union (QNMU) highlighted the ‘common practice of medication administration by unregulated carers’.98
3.78
The Australian Nursing and Midwifery Federation (SA Branch) (ANMF SA) stated that over the last two years, medication administration had moved to be the work of personal care assistants, but that they are not trained to dispense medication:
The level of training provided to personal care assistants does not provide them with the capacity to properly oversee medication administration, including assessing the need for medication changes, interactions and monitoring unintended reactions.99
3.79
The NSW NMA stated that recent research around medication management found that 83 per cent of those surveyed had ‘witnessed errors in the administration of medication’ and that 63 per cent had noted ‘a delay in people gaining adequate pain relief simply because there was no registered nurse there to administer the level of pain relief that was required’. Further, recent staffing changes at one facility had led medication being delivered according to staff shifts rather than need:
… the registered nurses in the day shift [had] to administer the medication before they left duty rather than at a time that might have been determined by the needs of the people who should have received them. They are good indicators that quality is slipping.100
3.80
The NSW NMA also stated that RNs have a significantly higher degree of training in medication management than a care worker, as RNs must undertake training in medication management during their three year graduate training whilst ‘an unlicensed care worker may receive two days of inhouse training’.101
3.81
Painaustralia set out that an RN must be physically present for the administration of an opioid, which can result in significant delays to the provision of pain relief to a resident. An example was given of a dying resident in ‘excruciating pain’, whose GP was prescribing an increasing amount of pain medication. The dispensing of the pain medication could ‘sometimes take up to five hours’ because the RN was required to attend to 200 residents and was delayed in being present for the resident.102
3.82
The LASA responded to this example, and stated that an RN should be provided if the skills mix for a facility required it, but stated that:
At the end of the day providing care is more than just providing clinical care; it is about providing their social and lifestyle requirements. The best outcome is really to enable the provider to provide the right skills mix necessary to meet the specific care needs of that person.103
3.83
UnitingCare Queensland stated that appropriate training and education for anyone assisting with medication was important, and that although ‘there is always a place for registered staff in administering medications … there is also a place for personal carers to be able to assist residents with medications’.104

Nutrition

3.84
Catering is assessed by the Quality Agency under Accreditation Standard 4.8 ‘Catering, cleaning and laundry services’, and food safety plans are reviewed during assessments.
3.85
The OPA Queensland stated that the provision of food is an area of concern for aged care residents’ family members:
We get a lot of people contacting our office concerned about their family members going into care and suddenly losing weight really rapidly. This is because the facilities don't have the staff to ensure that people can eat their meals. They place it before them and, if they don't eat it, they come back and take it away.105
3.86
Mrs Sue Smith described a poor quality of food served in a facility, and sought information on the food budget but was told that it was ‘confidential’. Mrs Smith also stated that the facility’s chef expressed frustration at the amount of money available to provide nourishing meals to residents.106
3.87
Mrs Kate Mannix stated that, after a complaint has been made regarding the quality of food in a facility, the assessment of catering is conducted on the ‘paper menu, rather than the food itself’.107
3.88
The inability of some residents to eat unassisted was raised by Ms Debra Aloschi and Ms Lisa Mooney, who stated that residents at a particular facility were considered to have eaten a meal if they ate three to four spoonfuls of food. Ms Aloschi and Ms Mooney further stated that if their mother was asleep when a meal was delivered at the facility, the meal was not kept and offered when the resident was awake. Ms Aloschi and Ms Mooney’s mother would also miss out on water due to communication issues which led to being hospitalised for dehydration:
We were constantly told that mum was ‘offered’ a drink and as she could not show any sign that she wanted the drink, it was not given to her. As mum could not speak or signal to anyone that she was thirsty, she missed out until the next meal.108
3.89
An inquiry participant, who did not wish to be named, described a resident being provided with pork despite expressed wishes to follow a diet that does not permit the consumption of pork meat products.109
3.90
The Health Care Consumers’ Association (HCCA) stated that residents of aged care facilities were being provided with medically inappropriate food, for example, diabetic residents not provided with diabetic meals. The HCCA also noted the effect of a lack of meal choice for residents, stating that it ‘is distressing for people who cannot eat certain foods for cultural or religious reasons and for people used to eating food they find palatable’.110
3.91
The HCCA also outlined a situation in which a facility had under-catered, which resulted in some residents missing out on a meal.111
3.92
A resident of an aged care facility, who did not wish to be named, described the food served as ‘not fit for dogs’, and stated that many residents do not eat the food because it is inedible and that no fresh fruit is provided.112
3.93
The Federation of Ethnic Communities’ Councils of Australia (FECCA) similarly stated that culturally appropriate food is not always available in residential aged care. The FECCA stated that the Chinese community is ‘not keen to age in a residential aged care facility’, partly due to the food provided.113

Lack of Assistance

3.94
Inquiry participants described the lack of assistance experienced by residents of aged care facilities and their family members. One inquiry participant, who did not wish to be named, stated that in one facility, the call bells to alert staff to an issue are not easily reached by residents and that staff do not check on residents who may become stuck in the facility’s garden.114
3.95
The Vintage Reds of the Canberra Region stated that call bells were not answered for issues regarding toileting, pain relief or assistance with meals, and stated that residents had been left alone in bathrooms or in a ‘wet or soiled bed’.115 Lengthy waiting times for call bell responses were also observed by Mrs Yvonne Buters.116
3.96
Ms Robyn Nolan described a lack of assistance for her father, who was a resident of an aged care facility. Ms Nolan stated that her father was:
Not assisted in attending the dining room, or provided with meals in his room when unable to attend the dining room;
Left off a list of residents for showering, and did not receive showering assistance;
Not assisted with cutting up food; and
Not assisted to access water as the water jug and glasses were placed out of reach, leading to dehydration.117

Current Reporting Mechanisms

3.97
Residential aged care providers have certain responsibilities regarding complaints resolution. The Aged Care Act sets out that an approved provider must:
Establish a complaints mechanism;
Use that mechanism to address complaints;
Advise the person of other mechanisms for complaint making;
Allow an authorised complaints office to have access to the service; and
Must comply with any requirement made under the Complaints Principles.118
3.98
Complaints regarding the standard of care in Australian Government-funded residential aged care facilities can be made by anyone to the Complaints Commissioner.
3.99
Major changes to the regulation of aged care services are scheduled to take effect on 1 January 2019, and will see the Quality Agency, Complaints Commissioner and aged care regulatory functions of the Department of Health form the Aged Care Quality and Safety Commission (Commission).119
3.100
Inquiry participants suggested that various aspects of the reporting process were in need of reform. The TCLS, for example, stated that reporting systems for restrictive practices, serious incidents, assessment of staff suitability and coronial reportability required reform.120
3.101
The Australian College of Nursing raised concerns that there was not uniform reporting of complaints across aged care facilities, as some facilities may have a ‘culture of underreporting’ but other staff may ‘over-report incidents due to fearing the consequences of not reporting [them]’. The result of over-reporting may lead to incidents being overlooked due to being ‘outnumbered by minor incidents’, and affecting morale, confidence and relationships with families’.121
3.102
The National Association of Community Legal Centres (NACLC) expressed the view that there are a ‘number of key issues’ in the reporting of assaults, and characterised the current reporting system as ‘weak’. The NACLC stated that major difficulties with the system included under-reporting due to fear of reprisal, the reportable assaults mechanism being discretionary and the need for staff members to report colleagues.122
3.103
The Department of Health advised that in 2015-2016, 71 non-compliance notices were issued to providers, with one provider’s accreditation revoked.123

Making a Complaint

3.104
In 2017-2018, 4315 complaints relating to residential aged care were made to the Complaints Commissioner. Of the total complaints (including complaints relating to home care or community care), around 56 per cent were made by family members or representatives of the resident.124
3.105
Of the complaints relating to residential services, the most common were:
medication administration and management (706);
personal and oral hygiene (473); and
personnel numbers/ratio (452).125
3.106
The Complaints Commissioner stated that a major focus has been to humanise the work of the agency, acknowledging that ‘it is not always an easy thing to raise a complaint’.126
3.107
The accessibility of the complaints system was questioned by inquiry participants. The Older Person’s Advocacy Network (OPAN) stated that, as the majority of complaints received by the Complaints Commissioner were made by family members or representatives, it considers ‘the mistreatment of residents to be under-reported by residents who are not actively engaged with family/friends/representatives’.127
3.108
The Australian College of Nursing put forward anecdotal evidence of residents’ families do not always understand how to make a complaint.128 Aged Care Crisis stated that the complaints system was difficult for consumers and family members to use:
Many simply give up and do not pursue their complaints. There is no one there to support the residents and families when they really need help and support in building confidence, advice when taking action and backing from those with clinical expertise when they confront those who have none.129
3.109
The Australian Association of Social Workers (AASW) characterised the complaints system as ‘onerous’, and stated that it ‘can be challenging for an older person to initiate and maintain a complaint against a provider in whose residential care they are living’.130
3.110
Dementia Australia also stated that there may be a ‘power imbalance’ between resident and provider, particularly if the resident has dementia:
In the case of people living with dementia, this power imbalance is further exacerbated as these individuals may also face issues such as lack of understanding of complaint mechanisms, limited capacity to engage with such mechanisms, communication difficulties and fear of reprisal.131
3.111
Carers NSW stated that carers may not make a formal complaint because ‘they did not believe it would produce a result’, that they ‘lacked the time or energy required’, or that the resident had changed providers or had passed away.132
3.112
Aged Care Crisis put forward some of the challenges faced by family members who have observed mistreatment and wish to complain:
Families who want to speak out lack power, are looked down on by providers, fear retaliation against their family member in care, face an opaque regulatory system that is not responsive to them and can be threatened with defamation.133

Timeframes for Complaint Resolution

3.113
The HCCA stated that the aged care complaints process is burdensome for consumers and family who are experiencing stress during a challenging time:
Making a complaint takes time and energy. There is an emotional cost too. As consumers of aged care services, we are often unwell or struggling with our health and capacity. Many people are too busy dealing with what life presents – such as caring responsibilities, or recovering from illness – to make a complaint they recognise as appropriate to make.134
3.114
Mrs Yvonne Buters characterised the complaints process as ‘difficult and onerous’,135 and described the emotional effect of a lengthy complaints resolution timeframe:
Over this period we have had to resend and re-visit disturbing photos, emails and evidence in regards to the case involving both our parents. This has resulted in continuing distress and the lack of ability to move forward.136
3.115
The Australian College of Nursing stated that the timeframes involved in resolving complaints may be ineffective, particularly for financial abuse. The Australian College of Nursing stated that ‘current systems are too slow to address indicators of financial abuse as too often funds are already depleted by abusers by the time actions are taken’.137
3.116
An inquiry participant, who did not wish to be named, stated that fast timeframes may not be beneficial to the person making the complaint:
I feel that the Aged Care Complaints Commission favours the aged care facility and not the resident and that they rush complainants to resolve disputes and do not provide complainants with adequate information about what changes the aged care facility will make to resolve concerns and prevent them from happening in the future.138
3.117
In 2017-2018, 93 per cent of complaints were resolved through ‘early resolution.’139 The Complaints Commissioner advised that early resolution involves ‘working directly between the parties, going back and forth, trying to get a result.’140 Of the 5738 total finalised complaints received by the Complaints Commissioner in 2017-2018, 4185 complaints were finalised within 30 days and 5330 within 90 days.141
3.118
The Complaints Commissioner has key performance indicators at resolving complaints by 30, 60 and 180 days, and stated that difficult cases take longer to resolve.142

Communication Barriers

3.119
The OPA Victoria stated that the current complaints process has flaws which are ‘most noticeable for people with cognitive impairment who can be limited in their ability to seek help or remove themselves from abusive situations’.143 The AMA similarly stated that complaints may not be taken seriously ‘if the patient is unable to directly articulate the issue’.144
3.120
Speech Pathology Australia expressed the view that residents with communication difficulties are ‘a particularly vulnerable group’ who can experience a power imbalance between themselves and the care provider:
The nature of communication disability exposes individuals to a higher potential for abuse, neglect and ill-treatment and also affects their ability to voice their concerns, to self-advocate, and to disclose/report harm done to them by another.145
3.121
Similarly, the Australian College of Nursing stated that residents with a severe degree of dementia ‘usually have no coherent speech and inadequate cognition to be able to report any instances of mistreatment’, which makes them ‘reliant on the culture and ethics of their professional carers for their welfare’.146
3.122
The OPA Queensland stated that people with impaired decision-making capacity may experience barriers to making complaints because:
The resident may not understand their rights;
The process or the entry points for making complaints are less accessible;
The resident may not be believed or taken seriously when they do make a complaint;
The resident is not able to manage and present evidence to support their complaint; and
A fear of reprisal or withdrawal of a service may lead to a reluctance to make a complaint.147
3.123
The OPA Queensland also identified that certain residents may require additional support to use a complaints system, and recommended that:
Complaints schemes for [residents with decision-making impairments] should therefore incorporate mechanisms that maximise accessibility of complaints management systems for people with impaired decision-making capacity and support to actively engage in the complaint-making process.148
3.124
An inquiry participant, who did not wish to be named, described the creation of a communication sheet for a resident who was not able to communicate, but which was not used by staff of the facility:
The family member was not able to communicate especially due to a medical condition that restricted communication. With my assistance and a speech therapist from an external service, a communication sheet with pictures and words that [they] can point to was composed. Sadly the staff did not use it. They relied on family members to pass on their info.149
3.125
The Victorian Multicultural Commission stated that multicultural older people require language support to communicate complaints and complete administration surrounding the complaints process:
The consequence of this support gap is that multicultural older people lose the ability to communicate their views and needs to staff and effectively lose their voice in their care management. This can and has led to many types of mistreatment and harm, including pain and discomfort, misdiagnosis of needs and medical conditions, incorrect medical treatment, mental health issues, withdrawal and isolation.150

Fear of Reprisal

3.126
Inquiry participants, including family members of residents and staff of aged care facilities, expressed a sense of fear at making a formal complaint regarding the quality of service in an aged care facility.151 Ms Fiona Duff stated that a person who has made a complaint may experience intimidation or harassment:
Whether you are a family member or staff member who is being the informer, your life will be turned upside down and soon filled with intimidation and harassment, threats of legal action and more. I have seen and experienced firsthand, both as a daughter, and through advocating aged care, supporting whistle blowers on their plight to come forward.152
3.127
Fear of reprisal by the provider was expressed by the Quality Aged Care Action Group (QACAG), which stated that ‘residents and relatives are stifled from making complaints because of the inherent fear of reprisals against either themselves, or their loved ones’. The QACAG described instances of residents and family members ‘being issued with warning letters by aged care providers when we have raised our concerns about poor quality of care’.153
3.128
Similarly, the Association of Independent Retirees - Fleurieu Peninsula Branch stated that residents of aged care facilities can ‘live in a stressful environment often in a state of fear through reprisals for those comments or complaints made’, and may feel vulnerable. A resident could ask someone to complain on their behalf, but when the advocate has left the facility, the resident ‘will be alone with staff central to the complaint’.154
3.129
An inquiry participant, who did not wish to be named, described the process of making a complaint as ‘very daunting’, and stated that they had ‘been a victim of retribution several times as well as experienced a threat for the intention to cause fear and cease a care concern matter going further’.155
3.130
The Western Australian Department of Health (WA Department of Health) stated that family members of residents are ‘anxious about being perceived as the “difficult family” and have concerns about the potential impact to the resident's ongoing treatment if they raise concerns’. The WA Department of Health further stated that having a ‘positive reporting culture’ would move away from the need for someone to act as a whistleblower.156
3.131
The ability for staff of aged care facilities to make a complaint regarding the quality of service was raised by representative bodies. The Health Services Union (HSU) stated that a survey of aged care workers in NSW had found that there was ‘significant pressure and fear of reprisal experienced by individuals who report incidents of resident mistreatment’:
More than half of those surveyed indicated that they had witnessed mistreatment of residents by family members, facility visitors, other residents, or staff. And yet, despite this, nearly a third of all anonymous survey participants reported feeling pressured by managers to not report critical incidents as they would reflect negatively on the [residential aged care facility].157
3.132
The QNMU called for ‘greater protection of employees in the aged care sector who wish to raise issues in relation to the quality of care provided to residents of aged care facilities’. The QNMU stated that a fear of reprisal from the provider may have led to a reluctance for aged care workers to make a complaint:
… many aged care employees are reluctant to make complaints related to the quality of care, poor facilities, resident neglect or the misappropriation of public funds because the potential for making such complaints may result in the termination of their employment, a reduction in the number of shifts or hours or other less favourable treatment.158
3.133
Greater protection of staff of aged care facilities was also recommended by Civil Liberties Australia, which stated that staff in these facilities are often vulnerable:
Staff of residential facilities need greater whistle blower protection than do average Australians: they are usually poorly paid, very job dependent, and relatively powerless in society. They fear sacking, which would in practice lead to virtually no chance to get a job in a similar facility.159

Fear of Restricted Access

3.134
Elderlaw commented that, when there is conflict between a provider and a resident’s family members in relation to the standard of care, ‘these cases can escalate to the stage of exclusion of the person who is accused of continual complaints about explicable incidents’.160 Elderlaw stated that there is no recourse for a family member who has been excluded, or whose access to the resident is restricted.
3.135
Elderlaw gave an example of a family member raising a number of concerns about the quality of care her mother was receiving, and who was then banned from accessing the facility, and therefore from her mother. Elderlaw stated that ‘during that term of ban her mother died’.161
3.136
The OPAN stated that the exclusion of family members from aged care facilities happens ‘frequently’, which creates a culture of under-reporting:
… we certainly frequently hear … that family members, when they start to raise concerns around issues, are excluded from facilities. So, again, there's a culture of: 'Don't raise it. I can no longer have my son or daughter visit because they've complained about the service.' Retribution is real.162
3.137
An inquiry participant, who did not wish to be named, stated that they had been banned from visiting a resident after raising concerns over the quality of care received by the resident. The inquiry participant moved the resident to another facility, as the resident was distressed by the family member’s absence.163
3.138
The QACAG also stated that people had been threatened with being banned from the aged care facility.164
3.139
The User Rights Principles 2014 provides that access must be granted to a person who has been asked to act for a residential aged care recipient. That person must be allowed access to the residential aged care service at any time.165

Protections for Reporting Mistreatment

3.140
The Department of Health advised that a range of protections exist for staff of approved providers of residential aged care under the Aged Care Act and the Australian Aged Care Quality Agency Act 2013 (Quality Agency Act). The Department of Health stated that:
A disclosure of information by a person qualifies for protection if the approved provider or a staff member discloses information to a police officer, the Department, the Complaints Commissioner, the Quality Agency, the approved provider or one of the approved provider’s key personnel or a person authorised by the approved provider.166
3.141
These protections will apply if the person making the disclosure: identifies themselves, has reasonable grounds to suspect that a reportable assault has occurred, and is acting in good faith in making the disclosure.167 Approved providers and staff who make a disclosure are protected from civil or criminal liability, and in proceedings for defamation relating to the disclosure. The Department of Health stated that a person’s contract may not be terminated on the basis of a disclosure, and that a disclosure made under the Aged Care Act would override an employment contract which prohibited discussion of issues arising in the aged care home.168
3.142
The Department of Health further advised that protections under the acts ‘do not extend to care recipients, their families and advocates, visiting medical practitioners, other allied health professionals, volunteers and visitors. Nor do they extend to disclosures of general failings in care’.169
3.143
Catholic Health Australia stated that staff are able to contact the Complaints Commissioner anonymously to report concerns over mistreatment, which may alleviate concerns ‘about how they might be treated both emotionally and psychologically by colleagues and management of the service, or that they might suffer financially’.170
3.144
The LASA stated that although whistleblowing is ‘recognised as a legitimate form of action in a democratic society’, it played a small role in the aged care system:
Importantly, the role of whistleblowers, should not be overstated in the overall system of quality assurance for aged care. In a well-designed system, adverse incidents are minimized and the handling of any adverse incidents that do occur is effective and efficient, so that the number of situations where a whistleblower may need to take action are very small.171
3.145
The LASA further stated that ‘better whistleblowing provisions may have assisted in the case of the Oakden incidents’, but that it was ‘not clear that this is an issue generally for residential aged care’.172
3.146
In contrast, the CPSA stated that the provisions of the Aged Care Act which relate to disclosure of information ‘virtually ensures that no one involved in residential aged care will become a whistle blower’. Further, the CPSA stated that the Aged Care Act’s definition of protected information includes ‘all information that relates to the affairs of an aged care provider, actual or prospective’.173
3.147
Volunteering Australia recommended that whistle blower provisions be extended to apply to the volunteer workforce in residential aged care.174 The QACAG called for more protection for residents, relatives and others to raise concerns regarding the quality of care.175 Civil Liberties Australia suggested an annual, national award for courage be administered for staff who raise issues over quality of care.176
3.148
The QNMU recommended that whistle blowers be permitted to make a disclosure to a third party in order to seek advice prior to making the disclosure. The QNMU stated that it advises nurses and midwives ‘who make a complaint or report or who are the subject of a complaint or report to seek support and advice from the QNMU in the first instance’. Further, the QNMU stated that, in its experience, ‘nurses and midwives seeking to disclose information may be unfamiliar with the reporting process for the relevant agency’, and that an error made during the disclosure process may potentially exclude a person from protection.177

Reportable Assaults

3.149
Approved providers must report allegations or suspicions of ‘reportable assaults’ to the police and to the Department of Health within 24 hours of becoming aware of the incident. Reportable assaults are ‘unlawful sexual contact or assault … or unreasonable use of force on a resident of an aged care home’.178 Such incidents may additionally be reported to the Complaints Commissioner.
3.150
If an assault is committed by a resident with a diagnosed cognitive or mental impairment, it is not required to be reported.179 In these instances, the provider must demonstrate to the Department of Health that the provider has ‘taken action within 24 hours, in an administrative way, to deal with that situation’.180
3.151
The Department of Health then assesses whether the provider has taken appropriate action and there is a safe environment for the resident. The Department of Health may take compliance action or refer the incident to the Quality Agency.181
3.152
In 2016-2017, 2853 notifications of reportable assaults were made to the Department of Health. Of those:
2463 were recorded as alleged or suspected unreasonable use of force;
348 as alleged or suspected unlawful sexual contact;
42 as both; and
130 incidents were referred to the Quality Agency.182
3.153
The Complaints Commissioner stated that data on the number of mandatory reportable assaults ‘is not a reliable measure of the extent of abuse in aged care’, as only some incidents are reportable assaults, assaults committed by someone with a cognitive impairment are not captured, and allegations or suspicions are captured which may not be substantiated.183
3.154
The ALRC stated that providers are required to keep records on reportable assaults, including the date the provider received the allegation, a brief description of the allegation, and whether a report has been made to the police and the Department of Health, or whether exemptions apply.184 There is no obligation for a provider to record any action taken as a response to the allegation.185
3.155
Estia Health stated that the current mandatory reporting of assaults ‘is no proxy for measuring mistreatment’, and that ‘it is unclear how the collection of this limited range of information is value adding’.186 Estia Health questioned the focus of the requirements:
These mandatory reporting arrangements are not a relevant response to dealing with abuse. The legislation seems to place more importance on reporting the allegation to police and the Department within 24 hours than it does to investigating the allegation and taking action.187
3.156
Estia Health recommended that unsubstantiated allegations of mistreatment should not be made to the Department of Health, that the definition of serious incidents be expanded, and that a provider should be able to report abuse by a person other than a staff member or resident.188
3.157
The OPAN also considered the current reportable assaults requirements as ‘inadequate in capturing the scope and prevalence of mistreatment within residential aged care’, and supported an expanded scope, which would offer ‘providers and consumers a more consistent understanding of what constitutes mistreatment’.189

The ‘Resident-on-Resident’ Exemption

3.158
The ALRC recommended the removal of the exemption relating to residents with cognitive impairments (known as the ‘resident-on-resident exemption’), and stated that these should be treated as serious incidents.190
3.159
The Carnell-Paterson Review agreed that assaults committed by a resident with a cognitive impairment should be reported.191
3.160
Dementia Australia acknowledged concerns that people with dementia can behave aggressively towards other residents and staff, and stated that the behaviour of those with dementia relates to broad issues around appropriate care and support.192
3.161
Dementia Australia stated that aggression by residents with dementia towards other residents and staff is ‘common, and poses a serious dilemma’, but was not of the view that aggression by people with dementia should be criminal abuse. Dementia Australia recommended the expansion of reportable assaults to include those perpetrated by residents with a cognitive impairment.193

Serious Incident Response Scheme

3.162
The ALRC recommended a serious incident response scheme replace the current responsibilities in relation to reportable assaults, and that it should require approved providers to notify ‘an independent oversight body’ of:
An allegation or a suspicion on reasonable grounds of a serious incident; and
The outcome of an investigation into a serious incident, including findings and action taken.194
3.163
The ALRC also recommended that the definition of a serious incident when committed against a recipient of residential care should include:
Physical, sexual or financial abuse;
Seriously inappropriate, improper, inhumane or cruel treatment;
Unexplained serious injury; and
Neglect.195
3.164
If committed by another recipient of residential care, the ALRC stated that the definition should mean sexual abuse, physical abuse causing serious injury, or an incident that is part of a pattern of abuse.196
3.165
The establishment of a serious incident response scheme was supported by the OPA Victoria, OPAN, and the Victorian Council of Social Service (VCOSS).197 VCOSS also stated that the scheme should ‘require providers to report on the outcome of the investigation into the incident and what action was taken’.198
3.166
The Aged Care Guild expressed support for the ‘intent’ of the serious incident response scheme, but stated that these practices are ‘largely followed by providers as a matter of best practice’. The Aged Care Guild also stated that it had concerns over an increased administrative burden:
… there is no evidence that a new [Serious Incident Response] Scheme would improve safety or quality. Instead, it would likely create a significant administrative burden, thereby directing time and resources away from caregiving duties. Any amendments to existing arrangements should be evidence-based and not introduce more compliance with no clear evidence or affect.199
3.167
The Council of the Ageing Australia (COTA Australia) stated that it did not wholly endorse a serious incident response scheme. Notwithstanding, COTA Australia agreed that providers should have appropriate systems in place to investigate incidents.200
3.168
The Department of Health advised that the ALRC recommendation for a serious incident response scheme is being considered.201

Concluding Comment

Measuring the Prevalence of Mistreatment

3.169
During the conduct of this inquiry, the Committee received evidence and heard personal accounts from a large number of individuals who made claims of mistreatment relating to family and friends in the aged care sector. Many of these individuals presented harrowing accounts of substandard care and treatment.
3.170
The true prevalence of mistreatment in residential aged care is not known, as only a limited range of data is regularly collected and published by the Department of Health. A strong desire for more comprehensive data to be published on a range of key indicators was expressed by inquiry participants, as well as a wish for the expansion of the reportable assaults mechanism.
3.171
The Committee considers that incidents of mistreatment should be measured more fully, and draw on a range of practical indicators, as the collection of data relating to mistreatment is an important function of the regulatory system and would provide consumer confidence in the aged care system moving forward.

Experiences of Mistreatment

3.172
Issues with the quality of care received by aged care residents around wounds and pain management were raised. Inquiry participants gave personal accounts of low standards of care for these matters, and detailed the effect this had on residents and their family members.
3.173
Personal accounts by residents, family members and staff of mistreatment in residential aged care detailed failings of care in the management of wounds and pain, the provision of medication, nutrition and lack of assistance for residents. Family members described the distress felt at seeing loved ones experience unnecessary pain, and frustration at their powerlessness to navigate the aged care complaints system.
3.174
Family members expressed fears of being excluded from visiting residents of aged care facilities as a means of reprisal for making any type of complaint. The Committee also received anecdotal evidence that complaints may be met with aged care providers stating that they would involve their lawyers. Inquiry participants raised issues around the imbalance of power between residents and aged care providers, as residents are reliant on the provider for their care and quality of life and may not be able to exercise their consumer rights and move to another facility or communicate issues.

Current Reporting Mechanisms

3.175
Various barriers to engaging fully with the current reporting mechanisms for mistreatment in residential aged care were put forward by inquiry participants. These barriers included communication difficulties as a result of dementia or language loss, the complexity of the complaints system for consumers and family members or advocates, and a fear of reprisal which would be felt by the resident or family member for raising issues.
3.176
Inquiry participants’ experiences of complaints process painted a picture of a system which is not accessible or user-friendly, and which may not result in noticeable outcomes for the resident. The system was characterised as bureaucratic and focussed on recording instances of alleged mistreatment, rather than on achieving an improvement to a resident’s quality of life.
3.177
The removal of the so-called ‘resident-on-resident’ exemption for reportable assaults, in which assaults committed by a resident with a cognitive impairment are not reported to the Department of Health, was recommended by inquiry participants. The reporting of these assaults would enable a truer measurement of mistreatment in residential aged care facilities. The Committee considers that there are sensitivities in requiring the reporting of these currently exempted assaults, due to the perpetrator’s impairment, but agrees that the exemption leads to a distortion of the incidence of mistreatment currently known.

Recommendation 8

3.178
The Committee recommends that the reportable assault ‘resident-on-resident’ exemption, in which assaults committed by a resident with a cognitive impairment are not required to be reported to the Department of Health, be removed.

Recommendation 9

3.179
The Committee recommends that the National Aged Care Quality Indicator Program (the Program):
be made mandatory for providers of Australian Government-funded residential aged care services; and
be expanded to include a broader range of key indicators, to be determined with the involvement of the aged care sector and consumer groups.

Recommendation 10

3.180
The Committee recommends that the Australian Government amend the Aged Care Act 1997 to legislate that:
the use of restrictive practices in residential aged care facilities be limited to the ‘least restrictive’ and be a measure of last resort only;
any use of restrictive practices within the legislated meaning be recorded by providers and collected by the Department of Health;
restrictive practices are only to be used after a medical practitioner has prescribed/recommended such use; and
the legal guardian and/or family member must be advised immediately.

  • 1
    My Aged Care, Elder abuse concerns, https://www.myagedcare.gov.au/legal-information/elder-abuse-concerns, Accessed 6 June 2018.
  • 2
    Dr Julie MacKenzie, Senior Legal Officer, Australian Law Reform Commission, Official Committee Hansard, Sydney, 5 March 2018, p. 2; Townsville Community Legal Centre, Submission 55, p. 3. The WHO definition is also referred to on the My Aged Care website, My Aged Care, Elder abuse concerns, https://www.myagedcare.gov.au/legal-information/elder-abuse-concerns, Accessed 6 June 2018.
  • 3
    World Health Organization, Elder abuse, http://www.who.int/ageing/projects/elder_abuse/en/, Accessed 17 May 2018.
  • 4
    Australian College of Nursing, Submission 57, pp 5-6.
  • 5
    Mr Rik Dawson, Director, Australian Physiotherapy Association, Official Committee Hansard, Melbourne, 6 March 2018, p. 1.
  • 6
    Vintage Reds of the Canberra Region, Submission 63, p. 2.
  • 7
    Townsville Community Legal Service, Submission 55, p. 3.
  • 8
    Townsville Community Legal Service, Submission 55, pp 3-4.
  • 9
    Aged Care Complaints Commissioner, Submission 28, p. 3.
  • 10
    Australian College of Nursing, Submission 57, p. 5.
  • 11
    Anglicare Australia, Submission 61, p. 4.
  • 12
    Leading Age Services Australia, Submission 29, p. 6.
  • 13
    Leading Age Services Australia, Submission 29, p. 6.
  • 14
    Vintage Reds of the Canberra Region, Submission 63, p. 12.
  • 15
    NSW Nurses and Midwives’ Association, Submission 6, p. 6.
  • 16
    Dr Anthony Bartone, Vice-President, Australian Medical Association, Official Committee Hansard, Canberra, 11 May 2018, p. 9.
  • 17
    New Aged Care, Submission 70, pp 5-7.
  • 18
    New Aged Care, Submission 70, p. 5.
  • 19
    Estia Health, Submission 84, p. 2.
  • 20
    Leading Age Services Australia, Submission 29, p. 6.
  • 21
    Ms Natalie Siegel-Brown, Public Guardian, Office of the Public Guardian Queensland, Official Committee Hansard, Brisbane, 26 April 2018, p. 37.
  • 22
    Aged Care Complaints Commissioner, Submission 28, p. 3.
  • 23
    Professor Joseph Ibrahim, Submission 31, p. 8.
  • 24
    Professor Joseph Ibrahim, Submission 31, p. 11.
  • 25
    Speech Pathology Australia, Submission 41, p. 5.
  • 26
    Catholic Health Australia, Submission 17, p. 1.
  • 27
    NSW Nurses and Midwives’ Association, Submission 6, p. 5; Mrs Kate Mannix, Submission 12, p. 2; Professor Joseph Ibrahim, Submission 31, pp 8-9; Victorian Council of Social Service, Submission 47, p. 4; Australian Association of Social Workers, Submission 51, p. 3; Vintage Reds of the Canberra Region, Submission 63, p. 2; Mr David Gavin, Submission 80, p. 3; Aged Care Crisis, Submission 90, p. 10.
  • 28
    Combined Pensioners and Superannuants Association of NSW, Submission 21, p. 3.
  • 29
    New South Wales Nurses and Midwives’ Association, Submission 6, p. 3; Dementia Australia, Submission 7, p. 25; Quality Aged Care Action Group, Submission 8, p. 4; Elderlaw, Submission 15, p. 3; Leading Age Services Australia, Submission 29, p. 8; Queensland Nurses and Midwives’ Union, Submission 44, p. 3; Australian Nursing and Midwifery Federation, Submission 53, p. 19; Townsville Community Legal Service, Submission 53, p. 7; Vintage Reds of the Canberra Region, Submission 63, p. 8; Law Council of Australia, Submission 86, p. 7; Aged Care Crisis, Submission 90 Attachment 1, p. 17; Health Services Union, Submission 92, p. 8.
  • 30
    Professor Joseph Ibrahim, Submission 31, p. 4.
  • 31
    Professor Joseph Ibrahim, Submission 31, pp 8-9.
  • 32
    Professor Joseph Ibrahim, Submission 31, pp 9-10.
  • 33
    Mr David Gavin, Submission 80, p. 4.
  • 34
    Department of Health, Submission 72, p. 8.
  • 35
    Department of Health, About the National Aged Care Quality Indicator Program, https://agedcare.health.gov.au/ensuring-quality/quality-indicators/about-the-national-aged-care-quality-indicator-programme, Accessed 6 June 2018.
  • 36
    Department of Health, Submission 72, p. 6.
  • 37
    Department of Health, About the National Aged Care Quality Indicator Program, https://agedcare.health.gov.au/ensuring-quality/quality-indicators/about-the-national-aged-care-quality-indicator-programme, Accessed 6 June 2018.
  • 38
    Professor Joseph Ibrahim, Submission 31, p. 8.
  • 39
    Professor Joseph Ibrahim, Submission 31, p. 10.
  • 40
    Dementia Australia, Submission 7, p. 15.
  • 41
    Aged Care Matters, Submission 13, p. 1; Australian College of Nursing, Submission 57, pp 3-4.
  • 42
    Aged Care Matters, Submission 13, p. 1.
  • 43
    Aged Care Matters, Submission 13, p. 1; Australian College of Nursing, Submission 57, pp 3-4.
  • 44
    Dementia Australia, Submission 7, p. 6; Mrs Sue Smith, Submission 9, pp 3-4; Aged Care Matters, Submission 13, p. 1; Australian College of Nursing, Submission 57, pp 3-4.
  • 45
    Dementia Australia, Submission 7, p. 6; Law Council of Australia, Submission 86, p. 11.
  • 46
    Aged Care Matters, Submission 13, p. 1; New Aged Care, Submission 70, p. 6.
  • 47
    Aged Care Matters, Submission 13, p. 1.
  • 48
    Aged Care Matters, Submission 13, p. 1.
  • 49
    Aged Care Crisis, Submission 90, p. 2.
  • 50
    Australian College of Nursing, Submission 57, pp 3-4.
  • 51
    Mrs Sue Smith, Submission 9, pp 3-4.
  • 52
    Dementia Australia, Submission 7, p. 3.
  • 53
    Dementia Australia, Submission 7, p. 3.
  • 54
    Care Guidance, Submission 82, p. 3.
  • 55
    National Aged Care Quality Indicator Program.
  • 56
    Accreditation reports for aged care providers contain the assessment of whether a provider has met or not met this standard, and elaborates on the criteria used.
  • 57
    Australian and New Zealand Society for Geriatric Medicine, Position Statement No 2 Physical Restraint Use in Older People, Revised September 2012, p. 1.
  • 58
    Office of the Public Advocate, Submission 60, p. 2.
  • 59
    Office of the Public Advocate, Submission 60, p. 2.
  • 60
    Ms Colleen Pearce, Public Advocate, Office of the Public Advocate (Victoria), Official Committee Hansard, Melbourne, 6 March 2018, p. 20.
  • 61
  • 62
    Office of the Public Advocate (Queensland), Submission 60, p. 7.
  • 63
    Townsville Community Legal Service, Submission 55, pp 8-9.
  • 64
    Law Council of Australia, Submission 86, p. 10.
  • 65
    Law Council of Australia, Submission 86, p. 11.
  • 66
    Australian Law Reform Commission, Submission 20, p. 2.
  • 67
    Australian Law Reform Commission, Submission 20, pp 2-3.
  • 68
    Ms Kate Carnell AO and Professor Ron Paterson ONZM, Review of National Aged Care Quality Regulatory Processes, October 2017, p. xii.
  • 69
    Australian and New Zealand Society for Geriatric Medicine, Position Statement No 2 Physical Restraint Use in Older People, Revised September 2012, p. 1.
  • 70
    Dr Peter Gonski, New South Wales Division Committee, Australian and New Zealand Society for Geriatric Medicine, Official Committee Hansard, Sydney, 5 March 2018, p. 13.
  • 71
    Dr Patricia Reyes, Secretary, New South Wales Division Committee, Australian and New Zealand Society for Geriatric Medicine, Official Committee Hansard, Sydney, 5 March 2018, pp 13-14.
  • 72
    UnitingCare Queensland, Submission 74 Supplementary Submission 2, p. 2. UnitingCare Queensland’s Memory Support Units are designed to support residents with dementia.
  • 73
    Mrs Margaret Daly, Submission 103, pp 1-2.
  • 74
    Aged Care Crisis, Submission 90, p. 73.
  • 75
    Name Withheld, Submission 43, p. 1.
  • 76
    Name Withheld, Submission 43, p. 1.
  • 77
    G W Hitchen, Submission 94, p. 12.
  • 78
    Dementia Australia, Submission 7, p. 26.
  • 79
    Accreditation Standard 2.4 Clinical care, Accreditation Standard 2.8 Pain management. Wound care is assessed under Accreditation Standard 2.3 Education and Staff Development.
  • 80
    Dr Anthony Bartone, Australian Medical Association, Official Committee Hansard, Canberra, 11 May 2018, p. 9.
  • 81
    Painaustralia, Submission 49, p. 1.
  • 82
    Painaustralia, Submission 49, p. 3.
  • 83
    Painaustralia, Submission 49, p. 3.
  • 84
    Ms Carol Bennett, Chief Executive Officer, Painaustralia, Official Committee Hansard, Canberra, 11 May 2018, p. 2.
  • 85
    Australian Pain Society, Pain in Residential Aged Care Facilities: Management Strategies, Second Edition, 2018.
  • 86
    Ms Goya Dmytryshchak, Submission 89, p. 3.
  • 87
    Name Withheld, Submission 69, p. 1.
  • 88
    G W Hitchen, Submission 94, p. 3.
  • 89
    Name Withheld, Submission 14, p. 2.
  • 90
    Name Withheld, Submission 77, p. 8.
  • 91
    Aged Care Complaints Commissioner, Annual Report 2017-18, p. 20.
  • 92
    Ms Catherine Rule, First Assistant Secretary, Aged Care Reform Taskforce, Department of Health, Official Committee Hansard, Canberra, 1 March 2018, p. 8, and Department of Health, Submission 72 Supplementary Submission 1, p. 2. The Health Practitioner Regulation National Law Act 2009 sets out the requirements for safe administration of prescription medicines.
  • 93
    Department of Health, Guiding principles for medication management in residential aged care facilities, 2012, p. 58.
  • 94
    Ms Kate Carnell AO and Professor Ron Paterson ONZM, Review of National Aged Care Quality Regulatory Processes, October 2017, p. 142.
  • 95
    Ms Kate Carnell AO and Professor Ron Paterson ONZM, Review of National Aged Care Quality Regulatory Processes, October 2017, p. 141.
  • 96
    Dr Peter Gonski, Australian and New Zealand Society for Geriatric Medicine, Official Committee Hansard, Sydney, 5 March 2018, p. 16.
  • 97
    Civil Liberties Australia, Submission 40, p. 6.
  • 98
    Ms Sandra Eales, Assistant Secretary, Queensland Nurses and Midwives' Union, Official Committee Hansard, Brisbane, 26 April 2018, p. 8.
  • 99
    Mr Rob Bonner, Director, Operations and Strategy, South Australian Branch, Australian Nursing and Midwifery Federation, Official Committee Hansard, Adelaide, 15 March 2018, p. 41.
  • 100
    Mrs Helen Macukewicz, Professional Officer, NSW Nurses and Midwives' Association, Official Committee Hansard, Canberra, 11 May 2018, p. 53.
  • 101
    Mrs Helen Macukewicz, NSW Nurses and Midwives' Association, Official Committee Hansard, Canberra, 11 May 2018, p. 53.
  • 102
    Ms Carol Bennett, Painaustralia, Official Committee Hansard, Canberra, 11 May 2018, p. 7.
  • 103
    Mr Robert Orie, Deputy Chairperson, Leading Age Services Australia, Official Committee Hansard, Canberra, 11 May 2018, p. 22.
  • 104
    Ms Cathy Thomas, Group Executive, Blue Care, South East Queensland, UnitingCare Queensland, Official Committee Hansard, Brisbane, 26 April 2018, p. 29.
  • 105
    Ms Mary Burgess, Public Advocate, Office of the Public Advocate Queensland, Official Committee Hansard, Brisbane, 26 April 2018, p. 35.
  • 106
    Mrs Sue Smith, Submission 9, p. 2.
  • 107
    Mrs Kate Mannix, Submission 12, p. 8.
  • 108
    Ms Debra Aloschi and Ms Lisa Mooney, Submission 68, pp 3-4.
  • 109
    Name Withheld, Submission 85, p. 8.
  • 110
    Health Care Consumers’ Association, Submission 66, p. 4.
  • 111
    Health Care Consumers’ Association, Submission 66, p. 5.
  • 112
    Name Withheld, Submission 18, p. 3.
  • 113
    Federation of Ethnic Communities’ Councils of Australia, Submission 50, p. 3. The FECCA further stated that other reasons include a fear of being socially and culturally isolated, and language barriers.
  • 114
    Name Withheld, Submission 18, p. 2.
  • 115
    Vintage Reds of the Canberra Region, Submission 63, pp 11-12.
  • 116
    Mrs Yvonne Buters, Submission 24, p. 1.
  • 117
    Ms Robyn Nolan, Submission 26, p. 3.
  • 118
    S56-4, Aged Care Act 1997.
  • 119
    The Department of Health will join from 2020.
  • 120
    Townsville Community Legal Service, Submission 55, p. 8.
  • 121
    Australian College of Nursing, Submission 57, p. 7.
  • 122
    National Association of Community Legal Centres, Submission 91, p. 3.
  • 123
    Ms Jo Mond, Assistant Secretary, Specialised Programs and Regulation Branch, Department of Health, Official Committee Hansard, Canberra, 1 March 2018, p. 2.
  • 124
    Aged Care Complaints Commissioner, Annual Report 2017-18, p. 20.
  • 125
    Aged Care Complaints Commissioner, Annual Report 2017-18, p. 20.
  • 126
    Ms Rae Lamb, Commissioner, Aged Care Complaints Commissioner, Official Committee Hansard, Melbourne, 6 March 2018, p. 22.
  • 127
    Older Person’s Advocacy Network, Submission 36, p. 2.
  • 128
    Australian College of Nursing, Submission 57, p. 8.
  • 129
    Aged Care Crisis, Submission 90, p. 36.
  • 130
    Australian Association of Social Workers, Submission 51, p. 4.
  • 131
    Dementia Australia, Submission 7, p. 8.
  • 132
    Carers NSW, Submission 30, p. 2.
  • 133
    Aged Care Crisis, Submission 90, p. 17.
  • 134
    Health Care Consumers’ Association, Submission 66, p. 6.
  • 135
    Mrs Yvonne Buters, Submission 24, p. 6.
  • 136
    Mrs Yvonne Buters, Submission 24, p. 2.
  • 137
    Australian College of Nursing, Submission 57, p. 7.
  • 138
    Name Withheld, Submission 76, p. 1.
  • 139
    Aged Care Complaints Commissioner, Annual Report 2017-18, p. 22.
  • 140
    Ms Rae Lamb, Aged Care Complaints Commissioner, Official Committee Hansard, Melbourne, 6 March 2018, p. 25.
  • 141
    Aged Care Complaints Commissioner, Annual Report 2017-18, p. 22.
  • 142
    Ms Rae Lamb, Aged Care Complaints Commissioner, Official Committee Hansard, Melbourne, 6 March 2018, p. 25.
  • 143
    Office of the Public Advocate Victoria, Submission 35, p. 4.
  • 144
    Australian Medical Association, Submission 23, p. 6.
  • 145
    Speech Pathology Australia, Submission 41, p. 3.
  • 146
    Australian College of Nursing, Submission 57, p. 12.
  • 147
    Office of the Public Advocate (Queensland), Submission 60, pp 8-9.
  • 148
    Office of the Public Advocate (Queensland), Submission 60, p. 9.
  • 149
    Name Withheld, Submission 77, p. 9.
  • 150
    Victorian Multicultural Commission, Submission 67, p. 6.
  • 151
    Combined Pensioners and Superannuants Association of NSW, Submission 21, p. 6; Mrs Yvonne Buters, Submission 24, p. 2; Older Person’s Advocacy Network, Submission 36, p. 1; Name Withheld, Submission 58, p. 1; Name Withheld, Submission 69, p. 2; Name Withheld, Submission 76, p. 1; Name Withheld, Submission 77, p. 1; Name Withheld, Submission 85, p. 1; Law Council of Australia, Submission 86, p. 12; Aged Care Crisis, Submission 90, p. 17; Health Services Union, Submission 92, p. 7.
  • 152
    Ms Fiona Duff, Submission 34, p. 1.
  • 153
    Quality Aged Care Action Group, Submission 8, p. 5.
  • 154
    Association of Independent Retirees - Fleurieu Peninsula Branch, Submission 19, p. 2.
  • 155
    Name Withheld, Submission 77, p. 1.
  • 156
    Western Australian Department of Health, Submission 88, p. 2.
  • 157
    Health Services Union, Submission 92, p. 7.
  • 158
    Queensland Nurses and Midwives’ Union, Submission 44, p. 12.
  • 159
    Civil Liberties Australia, Submission 40, p. 2.
  • 160
    Elderlaw, Submission 15, p. 9.
  • 161
    Mr Rodney Lewis, Senior Solicitor, Elderlaw, Official Committee Hansard, Sydney, 5 March 2018, p. 9.
  • 162
    Mr Geoff Rowe, Chief Executive Officer, Aged and Disability Advocacy Australia, Older Persons Advocacy Network, Official Committee Hansard, Brisbane, 26 April 2018, p. 15.
  • 163
    Name Withheld, Submission 85, p. 10.
  • 164
    Mrs Margaret Zanghi, Quality Aged Care Action Group, Official Committee Hansard, Sydney, 5 March 2018, p. 21.
  • 165
    8(1) User Rights Principles 2014.
  • 166
    Department of Health, Submission 72, p. 8.
  • 167
    Department of Health, Submission 72, p. 8.
  • 168
    Department of Health, Submission 72, p. 8.
  • 169
    Department of Health, Submission 72, p. 8.
  • 170
    Catholic Health Australia, Submission 17, p. 2.
  • 171
    Leading Age Services Australia, Submission 29, p. 10.
  • 172
    Leading Age Services Australia, Submission 29, p. 10.
  • 173
    Combined Pensioners and Superannuants Association of NSW, Submission 21, p. 5.
  • 174
    Volunteering Australia, Submission 39, p. 2.
  • 175
    Quality Aged Care Action Group, Submission 8, p. 6.
  • 176
    Civil Liberties Australia, Submission 40, p. 3.
  • 177
    Queensland Nurses and Midwives’ Union, Submission 44, pp 11-12.
  • 178
    Department of Health, Submission 72, p. 6.
  • 179
    Department of Health, Submission 72, p. 7.
  • 180
    Ms Jo Mond, Department of Health, Official Committee Hansard, Canberra, 1 March 2018, p. 3.
  • 181
    Department of Health, Submission 72, p. 7.
  • 182
    Department of Health, Submission 72, p. 8.
  • 183
    Aged Care Complaints Commissioner, Submission 28, p. 3.
  • 184
    Australian Law Reform Commission, Elder Abuse—A National Legal Response, May 2017, p. 112.
  • 185
    Australian Law Reform Commission, Elder Abuse—A National Legal Response, May 2017, p. 114.
  • 186
    Estia Health, Submission 84, p. 4.
  • 187
    Estia Health, Submission 84, p. 5.
  • 188
    Estia Health, Submission 84, p. 5.
  • 189
    Older Person’s Advocacy Network, Submission 36, p. 2.
  • 190
    Australian Law Reform Commission, Elder Abuse—A National Legal Response, May 2017, p. 123.
  • 191
    Ms Kate Carnell AO and Professor Ron Paterson ONZM, Review of National Aged Care Quality Regulatory Processes, October 2017, p. 114.
  • 192
    Dementia Australia, Submission 7, p. 11.
  • 193
    Dementia Australia, Submission 7, p. 11.
  • 194
    Australian Law Reform Commission, Elder Abuse—A National Legal Response, May 2017, p. 10.
  • 195
    Australian Law Reform Commission, Elder Abuse—A National Legal Response, May 2017, p. 10.
  • 196
    Australian Law Reform Commission, Elder Abuse—A National Legal Response, May 2017, p. 10.
  • 197
    Office of the Public Advocate (Victoria), Submission 35, p. 5; Older Person’s Advocacy Network, Submission 36, p. 2; Victorian Council of Social Service, Submission 47, p. 3.
  • 198
    Victorian Council of Social Service, Submission 47, p. 8.
  • 199
    Aged Care Guild, Submission 33, p. 14
  • 200
    Council of the Ageing Australia, Submission 37, p. 9.
  • 201
    Department of Health, Submission 72 Supplementary Submission 1, p. 10.

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