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Failing through the Gaps

Lately, we have had to ask ourselves whether our systems for keeping people safe are actually working. For our quality and safeguards expert Jess, the recent tragedies are deeply saddening, but not surprising. She explores what needs to change to ensure they do not happen again.

By Jessica Quilty

Updated 15 Apr 202413 Jul 2020

When I heard about Ann Marie’s death, like so many others, I felt overwhelmed with sadness. That sadness still plagues months on. Yet I can’t help but feel I have no right to grieve, I did not know her.

We’ve since had a number of cases of abhorrent abuse and neglect emerge in the media. Everyone is angry, rightfully demanding answers.

My colleagues know that quality and safeguarding is an area I am deeply passionate about, which lead to me being questioned about my lack of commentary on this particular case. I guess I felt like a climate change advocate after a catastrophic weather event. Everything you think can go wrong, does go wrong and you just feel helpless, even complicit. Because you knew the system was so fundamentally flawed. We also know that Ann Marie’s story is not unique.

When the Minister called this event “shocking”, it didn’t hit the right tone for me. Because to me, the word shock implies some sort of surprise or unexpected consequence. I am deeply saddened, appalled, outraged…but not surprised.

As a sector, we’ve lost a lot of logic in our quality and safeguarding approach.

Somewhere along the way, we seemed to have developed self-serving, compliance focussed systems designed to appease auditors rather than safeguard people. In a time of scarce resources and transformational change, this seems absurd, even negligent. Why does our sector accept it? The NDIS Quality and Safeguarding Framework was (and still is) a real opportunity for change.  It is a rich document that identifies the failings of past systems and reflects a numbers of key learnings:

“Risk assessment: it is generally agreed that a holistic assessment of the risks a participant faces, which takes into account their family circumstances, informal supports and individual capabilities is critical to enabling informed choice. It is also critical to identifying those who may be most at risk of abuse, violence, neglect and exploitation or who may be vulnerable to other risks, such as service provider failure. Families and carers, in particular, can play an important role supporting individuals to make choices about their supports.”

“Focusing on building the capability of participants and supporting them to make connections recognises that the actions people take themselves—or that their family, friends and others around them take—are likely to be the most important component of the quality and safeguarding system.”


When Ann Marie’s tragic story was splashed around the media, the community wanted justice. They demanded the Commission use its full regulatory powers. These are valid expectations, but we must not lose sight of a Framework that says:

“Investment in the developmental and preventative domains is intended to prevent adverse outcomes, so less corrective action is required.”

If these are indeed fundamentals, what progress have we made?

The Commission’s regulatory role is absolutely a key piece of this structurally flawed system, but they do not own its failure. We all do.

It is not surprising that this is where we have landed. We have been reminded continuously about an ‘NDIS watchdog’ monitoring provider’s every move. I guess the community expect police officers to police. But let’s not forget the education function that sits at the base of the Commission’s compliance pyramid. Perhaps we should also expect educators to teach?

I cannot help but feel that the rollout of the new Framework was a missed opportunity for collective vision and change. It focussed so heavily on compliance measures in relation to things like audits, incidents and complaints, despite the Framework recognising developmental safeguards as the most important aspect of keeping people safe. Perversely, when we focus on not getting into trouble, we tend to stop talking about good lives and keeping people safe. Last year, I received an insightful response to an article I wrote about an ordinary life and restrictive practices. A CEO expressed his concern that when organisations are faced with additional regulation and bureaucracy they often respond with concrete rules that only further depersonalise relationships. In the pursuit of an ordinary life, is this really where we want to head? We must tread carefully.

We are early in this new Framework, we can decide to change course.

Perhaps we need to start talking in plain, frank language to identify risk so that everyone gets it, and it is on all of our radars. Complex compliance and enforcement policies are not useful to time-poor managers or frontline workers. They keep people like me in a job but at what cost to people’s safety?

When I envisage safeguards, it comes in layers. We need to ensure multiple layers of safeguarding to make sure no person can fall through the gaps. A one size fits all won’t work as people have different vulnerabilities and support structures. Each person will be different, but this is how I view some of those layers we need to examine.

Self protection

All people that rely on others for intimate personal care are at increased risk. That vulnerability is further intensified by the way in which we wrap some people up in cotton wool. When we don’t nurture and build self-advocacy and protection, we fail people. That cotton wool is no good to anyone when they are in a position of unequal power. Further, if we don’t have safe and meaningful relationships modelled in our lives, we may find it difficult to identify abuse. This self protection layer is the most important because if systems fail (as they frequently do), it is all we have. I think of it as personal armour, but it seems to get the least attention in the quality and safeguarding space.

Risk taking

Denying opportunities to practice risk increases vulnerability. We often talk about dignity of risk as being in tension with duty of care, but I think we are more sophisticated than that. We take a very different response if we view risk in terms of short and long-term.

My children’s school made national news a couple of years ago after they banned cartwheels - A knee jerk risk mitigation strategy after some minor injuries (IMHO). If we step back and defog the glasses, some of the biggest risks to today's children is that they will be overweight, depressed or anxious. Inactivity and underdeveloped resilience, arguably the biggest fuel. Perhaps we actually have a duty of care to let people experience small shocks of hurt so they can build their resilience and risk assessment skills.

As parents, we support our children to gradually take on increased risk in a measured way. I have gone through quite an intentional risk taking process with my son, who engages in ‘high-risk behaviour.’  A short-term risk approach would be to not let him out on his own. But because my young boy will soon be a young adult, we have invested in reducing his long term vulnerability. We have implemented a program that focuses on incremental risk taking. The reality for him has been that he has gone from being far more restricted than other children his age to having more freedom than most. But it was gradual and intentional, we didn’t arrive there by accident.

Relationship building

We know that informal supports, also known as family, friends, people that love us, are foundational in keeping us safe. Yet we don’t include the requirement to build those connections into position descriptions and targets in the same way we do, say, workplace health and safety. My colleague Leighton Jay wrote a great article on the use of the F word that explores these concepts.

Closed systems

We are safer when we have multiple safeguards. People that rely on one organisation are at increased risk because they have only one layer of oversight. We are less likely to complain if it means breaking down our whole support structure and home life. I think of it as diversifying our safeguards. If one breaks down, others can step in. It also ensures multiple layers of scrutiny. There are still organisations with a dedicated quality and safeguarding team that continue to promote the cradle to grave, captured client model. We should challenge whether this is in anyone’s best interests. If we are genuinely committed to safeguarding, perhaps we should be actively encouraging participants to diversify supports to prevent those closed systems.

Complicated and fragmented systems

We need to consider the impact of slightly different state/territory requirements in the application of a nationally consistent approach, particularly when resourcing is limited. As the NDIS Quality and Safeguarding Framework states currently, quality and safeguarding measures vary between state, territory and Commonwealth funded services, and there is fragmentation between systems. The NDIS Quality and Safeguarding Framework needs to ensure that participants receive the same protections no matter where they live.

Our sector is great at developing mountains of paperwork that no one can follow. This is problematic for several reasons. Firstly it diverts scarce resources away from the core work of quality service delivery, from keeping people safe. Secondly, when people are confused, safety tends to suffer. If you make a support worker’s job too difficult, they will create work arounds. Nonsensically, when practice doesn’t align with policy, organisations often trip up at audit anyway - so these efforts may even be in vain.

I am a firm believer that if we had more input from people (staff and participants) and we wrote procedures down clearly, fewer incidents and errors would occur, people would be safer. Yet when the information we are handed down from the regulators is convoluted and confusing, what message is being sent to providers?

When we look at risk and vulnerability in plain speak, we see that police checks, incident reporting, compliance policies and auditing are simply not enough to keep people safe. Those are a few tools to aid a robust quality and safeguarding system. But the fundamental work that needs to happen is:

  • Identifying risk and vulnerability one by one.
  • Actively working to reduce vulnerability and strengthening personal armour.
  • Increasing social connections and relationships.
  • Identifying when a person is living in a closed system and actively working to change that.
  • Wrapping multiple layers of safeguarding around each person and testing to ensure they can never fall through the gaps.
  • Initiating corrective responses when those things do fail and clearly identifying the cause of the failure so we can fix it.


I hope Ann Marie’s death was not in vain, and we do some deep culture work in this area.

Let’s start talking about quality and safeguarding in real terms. Let’s give our risk management framework heart, a face…context, empathy, understanding, even real life application.

Let’s talk about people rather than compliance. We have an outcomes-focused set of standards, let’s start there. Does your organisation feel comfortable that it meets each of those outcomes? Would you trust the level of protection if it were you or your loved one that relied on it?  

Most importantly, are you confident that your organisation’s quality and safeguarding approach ensures that no one will ever suffer the same fate as Ann Marie?


Jessica Quilty

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