against people with disability in institutional and residential settings is
Australia's hidden shame...The evidence of this
national epidemic is extensive and compelling. It is a deeply shameful blight
on our society and can no longer remain ignored and unaddressed.
The issue of violence, abuse or neglect of people with disability was most
recently brought to national prominence by an ABC TV Four Corners investigation
of Yooralla disability services that aired on 24 November 2014.
The report contained allegations of long-term sexual assaults, physical and
psychological abuse and neglect of people with disability, as well as the victimisation
of whistleblowers. The allegations were not limited to one carer, nor limited
to one facility. The proceeding police investigation found five alleged
sexual offenders working for Yooralla as disability carers. Yooralla operates
over 70 residential care houses across Victoria.
The Four Corners report generated broad media and public attention to
the issue of violence and abuse of people with disability. On the eve of the
ABC TV report airing, the Victorian Government and Opposition both pledged to
hold an inquiry into that state's disability sector.
A range of organisations and disability advocates called for a national
inquiry, including former National Disability Commissioner, Mr Graeme Innes,
who said he believed there were dozens to hundreds of similar abuse and neglect
cases throughout Australia, and that the number of independent group homes
would shortly be increasing under the National Disability Insurance Scheme
(NDIS) rollout, increasing the need for a better system of independent
A coalition of peak disability advocacy groups renewed the campaign for a
national inquiry by writing to the Prime Minister on 20 January 2015.
The letter was endorsed by over 95 state and territory based disability
organisations from around Australia, with over 11,000 signatories to a petition
calling for an inquiry. In response, a group of Senators referred the matter on
11 February 2015, to the Senate Community Affairs References Committee (committee)
for inquiry and report.
Commonwealth responsibility for
As outlined in further detail in chapter two, the Commonwealth has
formally assumed certain responsibilities for disability services from 1
January 2009, under the National Disability Agreement (NDA). Formerly, the
Commonwealth's role was primarily one of funding states and territories to
deliver services, investing in policy priority initiatives and ensuring that
Commonwealth legislation is aligned with the United Nations (UN) Convention on
the Rights of Persons with Disabilities (the Disability Convention). However,
as a signatory to the Disability Convention, the Australian Government retains
ultimate responsibility to ensure that the treatment of people with disability
in Australia is compatible with the provisions of the Disability Convention.
Article 4 of the Disability Convention requires states to 'undertake to
ensure and promote the full realization of all human rights and fundamental
freedoms for all persons with disabilities without discrimination of any kind
on the basis of disability'.
This article places a positive obligation on the Australian Government to
ensure that these rights are not being infringed within its jurisdiction,
regardless of the entity inflicting the infringement.
Article 16 of the Disability Convention requires states to 'ensure that
all facilities and programs designed to serve persons with disabilities are
effectively monitored by independent authorities'.
This article places a positive obligation on the Australian Government to
ensure that disability services monitoring and complaints handling entities are
operating in an effective manner to uphold the rights of people with
Australia acceded to the Optional Protocol to the Disability Convention,
which came into force for Australia on 20 September 2009. The Optional Protocol
is a separate instrument to the Disability Convention, and gives the UN
Committee on the Rights of Persons with Disabilities the power to receive
complaints from individuals and groups who believe that their state has
breached the Disability Convention after all domestic remedies have been
There are currently nine individual cases/communications against
Australia pending under this mechanism.
Australia is also a signatory to the International Covenant on Civil and
Political Rights, the International Covenant on Economic, Social and Cultural
Rights, and the Convention on the Rights of the Child. The Disability
Convention captures relevant provisions of these other frameworks as they relate
to people with disability.
The committee's area of interest
The committee has a long-standing interest in the delivery of disability
services as part of its portfolio coverage of Health, Social Services and Human
Services. The committee's most recent relevant inquiries have focused on
aspects of disability service delivery to specific disability sectors. These
inquiries have included:
Adequacy of existing residential care arrangements available for
young people with severe physical, mental or intellectual disabilities in
Australia (June 2015);
Prevalence of different types of speech, language and
communication disorders and speech pathology services in Australia (September
Care and management of younger and older Australians living with
dementia and behavioural and psychiatric symptoms of dementia (March 2014).
The committee has also inquired into the practice of the forced
sterilisation of people with disability and people aging with a disability.
In this report, the committee examines the issue of violence, abuse and
neglect of people with disability from a whole of issue perspective. The
committee examines the causes of violence, abuse and neglect of people with
disability, what happens when individuals or their carers try to report abuse
either to the service delivery entity or through more formal mechanisms, and
what was the response to the reporting. The committee examines primary
ways that violence, abuse and neglect can be eliminated and how to improve
rates of reporting and responses to reporting via systemic changes. The
committee also examines secondary mechanisms that can support systemic change,
such as education programs, workforce improvements and advocacy programs.
Establishment of the inquiry
On 11 February 2015, the Senate referred an inquiry into violence, abuse
and neglect against people with disability to the committee for inquiry and
report by 24 June 2015. In order to properly respond to the volume of
evidence submitted to the inquiry, a series of extensions were granted by the
Senate, with a final reporting date of 25 November 2015.
Focus of the inquiry
The terms of reference for this inquiry were made deliberately broad,
to ensure the inquiry was able to look holistically at the issue of
violence, abuse and neglect of people with disability, which has many
intersecting causes and impacts. However, the terms of reference do constrain
the inquiry to acts of violence, abuse and neglect that occur within the
disability service setting. While the committee is aware that violence, abuse
and neglect of people with disability is prevalent in the community and is well
worth an inquiry itself, the causes and policy settings to address the issue
are distinct from such acts perpetrated within a disability service context.
The terms of reference include a definition of the disability service
settings relevant to this inquiry, and also provides a definition of violence.
Terms of reference
Violence, abuse and neglect against people with disability in
institutional and residential settings, including the gender and age-related
dimensions, and the particular situation of Aboriginal and Torres Strait
Islander people with disability, and culturally and linguistically diverse
people with disability, with particular reference to:
experiences of people directly or indirectly affected by violence, abuse and
neglect perpetrated against people with disability in institutional and
impact of violence, abuse and neglect on people with disability, their families,
advocates, support persons, current and former staff and Australian society as
incidence and prevalence of all forms of violence, abuse and neglect
perpetrated against people with disability in institutional and residential
responses to violence, abuse and neglect against people with disability, as
well as to whistleblowers, by every organisational level of institutions and
residential settings, including governance, risk management and reporting
different legal, regulatory, policy, governance and data collection frameworks
and practices across the Commonwealth, states and territories to address and
prevent violence, abuse and neglect against people with disability;
compliance with its international obligations as they apply to the rights of
people with disability;
and challenges of formal and informal disability advocacy in preventing and
responding to violence, abuse and neglect against people with disability;
should be done to eliminate barriers for responding to violence, abuse and
neglect perpetrated against people with disability in institutional and
residential settings, including addressing failures in, and barriers to,
reporting, investigating and responding to allegations and incidents of
violence and abuse;
- what needs to be done to protect people with disability from violence,
abuse and neglect in institutional and residential settings in the future,
including best practice in regards to prevention, effective reporting and responses;
identifying the systemic workforce issues contributing to the violence,
abuse and neglect of people with disability and how these can be addressed;
role of the Commonwealth, states and territories in preventing violence and
abuse against people with disability;
the challenges that arise from moving towards an individualised funding
arrangement, like the National Disability Insurance Scheme, including the
capacity of service providers to identify, respond to and prevent instances of
violence, abuse and neglect against people with disability; and
- what elements
are required in a national quality framework that can safeguard people with
disability from violence, abuse and neglect in institutional and residential
That for this inquiry:
and residential settings' is broadly defined to include the types of
institutions that people with disability often experience, including, but not
restricted to: residential institutions; boarding houses; group homes;
workplaces; respite care services; day centres; recreation programs; mental health
facilities; hostels; supported accommodation; prisons; schools; out-of-home
care; special schools; boarding schools; school buses; hospitals; juvenile
justice facilities; disability services; and aged care facilities; and
abuse and neglect' is broadly understood to include, but is not limited to:
domestic, family and interpersonal violence; physical and sexual violence and
abuse; psychological or emotional harm and abuse; constraints and restrictive
practices; forced treatments and interventions; humiliation and harassment;
financial abuse; violations of privacy; systemic abuse; physical and emotional
neglect; passive neglect; and wilful deprivation.
Conduct of inquiry
The committee advertised the inquiry in The Australian on 15
April 2015. Details of the inquiry were placed on the committee's website and
the committee wrote to 140 organisations, inviting submissions by 10 April 2015,
which was later extended to 29 May 2015. Submissions continued to be accepted
after that date. The committee received over 160 submissions. A list of the
individuals and organisations that made submissions to the inquiry is provided
at Appendix 1.
A total of six public hearings were held in Perth on 1 April 2015,
Melbourne on 30 June 2015, Canberra on 21 August 2015, Sydney on 27 August
2015, Adelaide on 28 August 2015 and in Brisbane on 16 October 2015. Organisations
from Tasmania were invited to participate in the Melbourne hearing, and
organisations from the Northern Territory were invited to hearings in South
Australia and Brisbane. Transcripts of hearings are available on the
and a list of the witnesses who gave evidence at the hearings is provided at Appendix
The committee thanks those individuals and organisations who contributed
to the inquiry, particularly those who provided evidence of their lived
experience of violence, abuse or neglect of themselves or their loved ones.
The committee is grateful for the cooperation of Commonwealth, state and
territory government departments in providing assistance to address this
significant national issue.
The committee commissioned an easy English version of the terms of
reference of the inquiry, as well as an easy English guide to how to make a
submission. Each guide was made available in a PDF version and a version
compatible with communication devices. The guides were published on the website
as well as distributed to the disability advocacy network, with advocates
encouraged to forward widely throughout their distribution lists. Advocacy
organisations provided positive feedback on this initiative, both informally
and formally to the committee.
The committee investigated options to allow submissions to be made as
audio or video submissions for those unable to provide a written submission. This
option was announced via the inquiry website and by email to the disability
advocacy network. No audio or video submissions were received.
The structure of the report
This report has 10 chapters, broken down by theme rather than closely
following the terms of reference.
Chapter two outlines Australia's obligations to people with
disability under various international human rights instruments. Chapter two
then outlines the frameworks of how disability services are provided, including
relevant commonwealth disability agreements which define the different
Commonwealth, state and territory roles in funding, policy development and
service provision. Chapter two also gives a brief overview of the recent
national, state or territory disability-related inquiries and reports.
Chapter three examines lived experience of violence, abuse and
neglect, covering the experiences of people with disability as well as the
experiences of family and friends who advocated on their behalf. Chapter three
also looks at the prevalence of violence, abuse and neglect of people with
disability and issues around data collection.
Chapter four investigates therapeutic and other disability
practice that would be seen in any other area of service as unlawful loss of
personal rights or even as acts of violence. This chapter considers issues such
as loss of legal capacity, restrictive practice and guardianship.
Chapter five examines the different legal and policy frameworks
for reporting and investigating violence, abuse and neglect, from informal
in-service reporting through to investigations by external government bodies
such as ombudsmen or commissioners.
Chapter six explores the issue of access to justice for people
with disability, and the barriers they face in reporting and providing evidence
Chapter seven looks at workforce and other systemic issues that
increase the risk of violence, abuse or neglect, and examines workplace and systemic
changes that could reduce the risk factors.
Chapter eight examines the important role of informal and formal
advocacy in reducing levels of, and responding to, individual acts of violence,
abuse or neglect.
Chapter nine looks at the challenges and opportunities presented
by the rollout of the NDIS in reducing violence, abuse and neglect against
people with disability.
Chapter ten draws together the committee conclusions made
throughout the report, to present a comprehensive road map for policy and law
makers to reduce the prevalence and impact of violence, abuse and neglect of
people with disability in institutional and residential settings.
References to the committee Hansard are to the proof Hansard – page
numbers may vary between the proof and official transcript.
The terms of reference for this inquiry do not provide a definition of
disability. The committee has relied on the definition in Article 1 of the Disability
Persons with disabilities include those who have long-term
physical, mental, intellectual or sensory impairments which in interaction with
various barriers may hinder their full and effective participation in society
on an equal basis with others.
The UN Handbook for Parliamentarians on the Convention on the Rights
of Persons with Disabilities provides a more extensive definition,
stressing that the impact of disability is not caused by a disability itself,
but in the intersection of an impairment which 'in the face of various negative attitudes or physical
obstacles, may prevent those persons from participating fully in society'.
committee has kept this extended definition in mind when assessing the evidence
put forward during the inquiry. It is particularly relevant to the issue of
reporting and prosecuting acts of violence, abuse and neglect of people with
disability, where the disability is often seen by the justice system as an
insurmountable barrier to gathering credible evidence on which to prosecute an
Defining violence, abuse or neglect
The terms of reference provide a definition of violence. This definition
was developed in collaboration with key experts within the disability sector to
ensure that all aspects of violence, abuse and neglect relevant to people with
disability were captured.
Although the terms of reference limit the locations relevant to this
inquiry to places of institutional or residential care, such as residential
institutions, boarding houses, group homes, schools, aged-care facilities etc.,
the definition of violence includes domestic, family and interpersonal
violence. This is to reflect situations where such acts of violence occur
within institutional or residential care settings, and the care provider
does not live up to their duty of care in protecting their vulnerable clients
against such acts of violence, abuse or neglect, regardless of who is the
Numbers of people with disability
Just under one in five people (4.2 million people or 18.5 per cent of
Australians) reported having a disability in 2012. For those people with
disability, 3.7 million (88 per cent) had a specific limitation or
restriction that meant they were limited in the core activities of self-care,
mobility or communication, or restricted in schooling or employment
(see Figure 1.0 below).
Almost one in five people with disability (19 per cent or 813,900
people) reported a mental or behavioural disorder as the long-term health
condition causing them the most problems. This included 5.6 per cent with
intellectual and developmental disorders, 3.8 per cent with depression and mood
affective disorders and 2.1 per cent with dementia and Alzheimer's disease.
Figure 1.1: All Persons, Disability status
and living arrangements
Source: ABS, Survey of Disability, Ageing and Carers,
Australia: Summary of Findings, Disability Characteristics, ABS, Canberra,
Overall, in 2012, there continued to be a smaller proportion of males
with disability than females (18 per cent compared with 19 per cent). This
difference was most pronounced in older age groups for those with a profound or
severe core activity limitation (40 per cent for females compared to 26 per
cent for males 75 years and over). The other notable difference between males
and females was that more boys than girls in the age group five to 14 years had
disability (11.2 per cent compared with 6.2 per cent).
ATSI and CALD communities
Aboriginal and Torres Strait Islander peoples experience higher rates of
disability than do other Australians. After taking into account age differences
between the Indigenous and non-Indigenous populations, the rate of disability
among Aboriginal and Torres Strait Islander peoples is almost twice as high as
that among non-Indigenous people.
People from culturally and linguistically diverse backgrounds—in
particular newly arrived migrants such as refugees and special humanitarian
entrants—can be particularly vulnerable. Those with disability are likely to
experience multiple disadvantages. Lack of accessible information,
communication difficulties or cultural sensitivities and differences can create
barriers to services and support.
There are differences in disability prevalence across Australia's states
and territories, due in part to the differing age structures. In 2012, Tasmania
had the highest prevalence of disability, with a quarter of that state's
population living with disability, compared with 16 per cent in Western
Australia or the Australian Capital Territory and 12 per cent in the Northern
Territory. The proportion of the population living with disability increases
considerably with age. Tasmania also had the highest proportion of people aged
65 years and over with disability (55 per cent), while the Australian Capital
Territory had the lowest proportion (44 per cent).
Overall, there is a smaller proportion of people living with disability
in Australia's major cities than in regional areas (17 per cent and 22 per cent,
In 2012, of the population of older Australians with disability, most
lived in a private dwelling (85 per cent) and needed some form of assistance
(56 per cent) with one or more activities of daily life.
While the majority of older people with disability lived with others, there
were around 61,300 older people with a profound core activity limitation living
alone in a private dwelling in 2012.
In 2012, around 1.4 million older people needed assistance with at least
one activity because of disability or age (42 per cent). Assistance was most
commonly needed for health care tasks (25 per cent) and property maintenance
(23 per cent). Of those people with disability, living in households,
older people were more likely to report that their need for assistance had been
met in full than those aged under 65 years (64 per cent compared with 58 per
cent), while 5.8 percent of those aged under 65 reported their needs were not
being met at all.
Prevalence of violence, abuse and
There are no definitive statistics on the prevalence of violence, abuse and
neglect specific to people with disability, let alone broken down into place of
residence such as institutional settings versus private residences. What is
known through various studies, discussed in further detail in chapter two, is
that the rate of violence and abuse of people with disability is far higher
than for people without disability, and that issues of neglect are higher for
people who require assistance with the provision of basic living needs.
The National Disability Strategy reports:
There is a range of evidence which suggests that people with
disability are more vulnerable to violence, exploitation and neglect. People
with disability fare worse in institutional contexts where violence may be more
common. People with disability are more
likely to be victims of crime and there are also indications that women face
18 per cent of people with a
disability report being victims of physical or threatened violence compared to 10
per cent without.
The National Police Research Unit
at Flinders University studied 174 people with an intellectual disability and
found that they were 10 times more likely to have experienced abuse than
A recent US study found that women
with disabilities were 37.3 per cent more likely than women without a
disability (20.6 per cent) to report experiencing some form of intimate partner
violence. 19.7 per cent of women with disabilities reported a history of
unwanted sex compared to 8.2 per cent of women without a disability.
The Australian Cross Disability Alliance wrote:
It is almost impossible, in a written Submission, to do
justice to the magnitude of the issue of violence against people with
disability in institutional and residential settings in Australia. It is also
impossible in a written Submission, to articulate the life-long pain and
suffering endured by people with disability who have experienced and who
continue to experience violence, abuse, exploitation and neglect in these
In preparing this inquiry report, the committee echoes the above
sentiment expressed by the disability advocacy sector peak body, the Australian
Cross Disability Alliance. It has been a challenging task for this inquiry to
adequately capture the scale of the epidemic of violence, abuse and neglect of
people with disability and the toll this epidemic has had on individuals and
their families. The committee acknowledges the vast body of evidence presented
by all submitters and witnesses. Although the final report can only present a
small portion of the individual experiences, every individual account of
suffering and pain has helped the committee to a greater understanding of the
nature and scale of the problem to be addressed. In the words of one witness to
We bear witness to the stories and Australia's shame.
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