Notification Form - Part A · Disability Reportable Incidents Division – Notification Form Part A1 – Client to client – December 2015 3.16oes the person receive informal decision

1NSW Ombudsman Disability Reportable Incidents Division – Notification Form Part A1 – Client to client – December 2015

Notification Form - Part A A1: Client to Client Incident

What is a client to client incident?A client-to-client incident involves an assault of a person with disability living in supported group accommodation by another person with disability living in the same supported group accommodation that:

i) is a sexual offence, or

ii) causes serious injury (including, for example, a fracture, burns, deep cuts, extensive bruising or concussion), or

iii) involves the use of a weapon, or

iv) is part of a pattern of abuse of the person with disability by the other person.

Instructions for completing and sending the notification form to the OmbudsmanThis form is to be used to notify the Ombudsman’s office of a reportable incident in disability supported group accommodation.

This is a pdf template and does not save automatically. To save the document use ‘save as’ and place on your system before completing.

Note: The text boxes are a fixed size. If additional space is required, please attach separately with the form.

Part A of the notification form, relating to the details of the people involved, the allegation and the agency’s initial response, is to be sent to the Ombudsman’s office within 30 days of the head of FACS or a funded provider becoming aware of the reportable incident.

Once your agency has completed an investigation into the reportable allegation, and you have finalised your risk management response, please also complete Part B of the notification form.

If you require assistance please contact the Ombudsman’s Disability Reportable Incidents Division on 02 9286 1000.

Delivery instructionsTo maintain a high level of confidentiality, please send the notification form and any other documents relating to the investigation to the Ombudsman by:

• registered mail

• hand delivery, or

• courier

Addressed to:

Attention: Disability Reportable Incidents Division NSW Ombudsman Level 24 580 George Street Sydney NSW 2000

A1

2 NSW Ombudsman Disability Reportable Incidents Division – Notification Form Part A1 – Client to client – December 2015

1. Agency details1.1 Name of agency:

1.2 Head of agency:

1.3 Position title:

1.4 Signature:

1.5 Date:

1.6 Agency contact details:

Postal address: (not a home address)

Telephone: Email:

1.7 Your case/reference number (if known):

1.8 If this notification relates to any other notification(s) or inquiries made to the Ombudsman, provide our reference number(s) or other details:

1.9 Agency type:

Department of Family and Community Services

Non-government funded provider

Other public authority

1.10 Does your organisation receive funding under the Disability Inclusion Act 2014?

No Yes

1.11 Does your agency provide services to children (ie. clients under 18 years)?

No Yes

If another officer is preferred as the contact person regarding this notification provide their details below.

1.12 Contact officer:

1.13 Position title:

1.14 Contact details (if different from above):

Postal address: (not a home address)

Telephone: Email:


2. Details of the client who is the subject of allegationThis section needs to be completed for each client who is the subject of allegation.

2.1 Does this notification contain allegations against more than one client?

No Yes, how many?

CLIENT:

2.2 Given names:

Family name:

2.3 Gender: Male Female Transgender Intersex

2.4 Date of birth:

2.5 Age of the client at the time of the incident:

2.6 Address and name of supported accommodation:

2.7 Length of time residing at supported accommodation:

2.8 Number of other residents:

2.9 Type of residence Group home Residential facility Respite

Other (specify):

2.10 Is the client receiving NDIS funding? No Yes

2.11 Details of the client’s disability:

Autism spectrum

Developmental delay (up to age 6)

Intellectual impairment (specify): Mild Moderate Severe Profound Unknown

Other cognitive impairment

Mental Health

Neurological impairment

Physical impairment

Sensory impairment

Other (specify):

Unknown


2.12 Does the client have behaviour support needs?

Absconding

Eating non-food items

Other behaviour

Property destruction

Self-harm

Violence towards others

Other (specify):

2.13 How does the person communicate?

Verbal communication

Adjusted verbal language – such as the use of selected words or sound

Electronic communication

Picture communication

Sign language

Other signing

Other – such as use of gestures

2.14 Is the client:

Aboriginal and/or Torres Strait Islander: No Yes Unknown

Of culturally and linguistically diverse (CALD) background: No Yes Unknown

2.15 If the client is a child, is parental responsibility for the child with the Minister for Family and Community Services?

No Shared responsibility Yes

2.16 Is a guardian appointed for the client?

No

Yes, Public Private

Functions of the guardianship order: Accommodation Medical dental

Health care services Restrictive practices Advocacy

Other (specify):

2.17 Does the person receive informal decision making support from family/friends/advocate? No Yes

2.18 Have prior allegations been made against the client?

No Yes, please answer the following questions:

Please provide details of what was/were the allegation/s?


Date:

When was the most recent allegation? Date:

Was any action taken as a result of the allegation/s?

No action taken

Yes (specify):

Please provide details of the reportable incident/allegation

3. Details of the client who is the alleged victimIf more than one alleged victim is involved, please complete this section of the form for each person. Please fill in a new form if there are more than 3 clients involved.

3.1 Does this notification involve more than one alleged victim?

No Yes – how many? Unknown

CLIENT ONE:

3.2 Given names:

Family name:


3.4 Date of birth:

3.5 Age of the client at the time of the reportable incident:

3.6 Name and address of supported accommodation:


3.8 Number of other residents, if known:

3.9 Type of residence: Group home Residential facility Respite

Other (specify):



3.11 What is the alleged victim’s disability?

Autism spectrum




Mental Health


Physical impairment

Sensory impairment

Other (specify):

Unknown


Absconding


Other behaviour


Self-harm


Other (specify):






Sign language

Other signing


3.14 Is the client:




No

Yes, Public Yes, Private

Functions of the guardianship order:

Accommodation Medical dental


Other (specify):



3.17 If the alleged victim is a child, is parental responsibility for the child with the Minister for Family and Community Services?


CLIENT TWO:

3.2 Given names:

Family name:


3.4 Date of birth:






Other (specify):



Autism spectrum




Mental Health


Physical impairment

Sensory impairment

Other (specify):

Unknown


Absconding


Other behaviour



Self-harm


Other (specify):






Sign language

Other signing


3.14 Is the client:




No





Other (specify):




CLIENT THREE:

3.2 Given names:

Family name:


3.4 Date of birth:







Other (specify):



Autism spectrum




Mental Health


Physical impairment

Sensory impairment

Other (specify):

Unknown


Absconding


Other behaviour


Self-harm


Other (specify):






Sign language

Other signing


3.14 Is the client:





No





Other (specify):




4. Details of the reportable incident/allegation/s If more than one reportable incident/allegation is involved, please complete this section for each incident/allegation.

4.1 Does this notification concern more than one reportable incident/allegation?

No Yes, how many?

INCIDENT ONE:

4.2 Date of alleged incident, if known:

or period from: to

4.3 Date the head of your agency became aware of the incident/allegation/s:

4.4 Location where reportable incident/allegation occurred

Group home Residential facility Respite – centre-based Respite – flexible

Day program Employment service Other (specify):

4.5 Detailed description of reportable incident/allegation


4.6 Name and role of the first person who became aware of the incident/allegation:

4.7 Name and role of person who reported the incident/allegation to the head of agency:

4.8 Type of client to client reportable incident/allegation [For further information, please see the Guide for services: Reportable incidents in disability supported accommodation on the NSW Ombudsman website: www.ombo.nsw.gov.au.]

Sexual offence

Sexual assault

Aggravated sexual assault

Indecent assault

Act of indecency

Physical assault causing serious injury

Fracture

Burns

Deep cuts

Extensive bruising

Concussion

Other type of serious injury (specify):

Physical assault involving the use of a weapon

Type of weapon or object used for the purposes of being a weapon (specify):

Pattern of abuse

Repeated abuse of a sexual nature

Repeated physical force or inappropriate physical contact

Repeated threats of physical force or threats of inappropriate physical contact

Repeated conduct that causes physical harm to the victim

Repeated conduct that causes emotional harm to the victim

Contravention of an apprehended violence order [This category relates to an incident occurring in supported group accommodation and involving a contravention by a person with a disability of an AVO made for the protection of another person with a disability living in the same supported group accommodation.]


Reportable conviction [This category is only applicable when a matter has been proven at court.]

Sexual offence

Physical assault

Contravention of an apprehended violence order

Other (specify):

INCIDENT TWO:


or period from: to




Day program Other (specify):




4.8 Type of client to client reportable incident/allegation (For further information, please see the Guide for services: Reportable incidents in disability supported accommodation on the NSW Ombudsman website: www.ombo.nsw.gov.au.)

Sexual offence

Sexual assault


Indecent assault

Act of indecency



Fracture

Burns

Deep cuts

Extensive bruising

Concussion




Pattern of abuse






Contravention of an apprehended violence order (This category relates to an incident occurring in supported group accommodation and involving a contravention by a person with a disability of an AVO made for the protection of another person with a disability living in the same supported group accommodation.)

Reportable conviction (This category is only applicable when a matter has been proven at court.)

Sexual offence

Physical assault


Other (specify):

INCIDENT THREE:


or period from: to




Day program Other (specify):





4.8 Type of client to client reportable incident/allegation [For further information, please see the Guide for services:[Reportable incidents in disability supported accommodation on the NSW Ombudsman website: www.ombo.nsw.gov.au.]

Sexual offence

Sexual assault


Indecent assault

Act of indecency


Fracture

Burns

Deep cuts

Extensive bruising

Concussion




Pattern of abuse







Contravention of an apprehended violence order [This category relates to an incident occurring in supported group accommodation and involving a contravention by a

person with a disability of an AVO made for the protection of another person with a disability living in the same supported group accommodation.]

Reportable conviction (This category is only applicable when a matter has been proven at court.)

Sexual offence

Physical assault


Other (specify):

5. Interim action taken or proposed by agency 5.1 Did your agency undertake a risk assessment when the incident/allegation was identified?

Yes, please provide a copy of the risk assessment

No, why?

5.2 What action has been taken or is proposed while the incident/allegation is being investigated? Please include details of action taken for the client who is the alleged victim.

Review of staffing/supervision

Increased supervision

Review of and/or change in accommodation arrangements

Review of and/or change to behaviour support needs

Review of medical/health needs

Change in health support provided

Review of psychological/mental health needs

Change in psychological/mental health support provided

Education for the client/s

Training for staff

Review of legal/ decision-making capacity

Referral/assistance to access legal support

Referral/assistance to access a support person

Other (specify):

No action (state the reason):

Please specify the details of all action taken or proposed for each client


5.3 What action has been taken or is proposed while the incident/allegation is being investigated? Please include details of action taken for the client who is the subject of allegation.

Review of staffing/supervision

Increased supervision

Review of and/or change in accommodation arrangements

Review of and/or change to behaviour support needs

Review of medical/health needs

Change in health support provided

Review of psychological/mental health needs

Change in psychological/mental health support provided

Education for the client/s

Training for staff

Review of legal/decision-making capacity

Referral/assistance to access legal support

Referral/assistance to access a support person

Other (specify):

No action (state the reason):

Please specify the details of all action taken or proposed for each client

5.4 Has the NSW Police Force been informed of the incident/allegation? [Agencies must report allegations of a criminal nature to the NSW Police Force. The main purpose of a police investigation is to make inquiries to determine whether there is sufficient evidence to charge a person with a criminal offence. Advice should be obtained from the NSW Police Force before commencing an investigation.]

No, why?

Yes. If yes, please provide:

Date of report to police:

Police event number:

Police Local Area Command reported to:

Name of investigator reported to:

Not applicable

5.5 Is the NSW Police Force investigating the incident/allegation?

No Yes Unknown


For matters referred to the NSW Police Force, your agency will need to obtain police clearance prior to continuing with your workplace investigation.

5.6 Support provided to the alleged victim/s (please repeat for each alleged victim)

Has support been offered/provided to the alleged victim?

No, why not?

Yes, what kind?

Are the client’s family or guardian aware of the incident/allegation? [Consent should be sought from adult clients (AV and/or SOA) before informing guardians, families and other supporters of the

allegation of abuse or neglect. Where the client has provided consent (or they are unable to provide informed consent), their guardian, family and/or key supporter should be informed of the allegation as soon as possible after the report is made. For children, their parent or guardian should generally be advised unless there are compelling reasons for believing that by providing a parent or guardian with advice about an allegation the client will be exposed to harm. In these circumstances, you should consult an expert e.g. police or FACS child protection services.]

No, why?

Not applicable, why?

Yes

5.7 Support provided to the client who is the alleged subject of allegation (please repeat for each client subject of allegation)

Has support been offered/provided to the client subject of allegation?

No, why not?

Yes, what kind?

Are the client’s family or guardian aware of the allegations? [Consent should be sought from adult clients (AV and/or SOA) before informing guardians, families and other supporters of the

allegation of abuse or neglect. Where the client has provided consent (or they are unable to provide informed consent), their guardian, family and/or key supporter should be informed of the allegation as soon as possible after the report is made. For children, their parent or guardian should generally be advised unless there are compelling reasons for believing that by providing a parent or guardian with advice about an allegation the client will be exposed to harm. In these circumstances, you should consult an expert e.g. police or FACS child protection services.]

No, why?


Yes

5.8 If the allegation relates to a child:

Has the FACS Child Protection Helpline been informed of the reportable incident/allegation?[Agencies must report suspected risk of significant harm to children to the FACS Child Protection Helpline. The main purpose of a FACS investigation is to identify whether a child is at risk of significant harm and whether any care and support issues exist. Advice should be obtained from FACS before commencing an investigation.]

No


Yes. If yes, please provide:

Date of report:

Reference number:

Community Service Centre:

Is FACS investigating the incident/allegation? No Yes Unknown


6. Documents attachedThe Ombudsman requires a copy of all materials which were considered by your agency during the investigation into the reportable incident. Please attach copies of any relevant documents. This may include, but is not limited to, the following:

Information about the reportable allegation/incident

Incident report/s

Medical reports

Progress notes

Communication profile

Correspondence regarding reportable allegation

Rosters related to the period of the allegation/incident

Relevant workplace policies and procedures

Information related to referral to NSW Police

AVO

Agency documentation related to the AVO (eg. staff advice and guidance re. compliance with AVO)

Information about the clients involved in the reportable incident/allegation

Lifestyle or individual plan

Client risk plan

Health care plan, health care profile and any specific health support plans

Behaviour support plan

Restrictive practice authorisation

Capacity assessment

Consents

Transition plans

Information about any interim action taken

Risk assessments and risk management action

Any other interim action taken including change in accommodation arrangements/support

Any other relevant materials