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An urgent review prompted by the death of Ann-Marie Smith in South Australia has found the National Disability Insurance Scheme (NDIS) needs to get better at identifying vulnerable care recipients, and improve the supervision of in-home workers.
The State Government of South Australia set-up a 12-member Task Force last month to examine gaps in oversight and safeguarding for people living with disability in South Australia.  The Interim Report was released earlier this week.
We have listed below the 12 Gaps identified in the Interim Report, followed by the five Recommendations listed in the Interim Report.  You can read the full Interim Report in PDF at

Safeguarding Gaps identified

  1. Vulnerable participants are not routinely identified and assigned ongoing support coordination in their NDIS Plan.
  2. The support coordinator can be from the same agency that provides other core services for the individual, creating a conflict of interest.
  3. Participants need to be able to link to community so that they can participate in community activity. This has been the designated role of Local Area Coordination.
  4. Participants who are identified as vulnerable by the NDIA need to be prioritised when carrying out the community connection role.
  5. NDIS plans need to be inclusive of strategies to minimise participant risk e.g. coordination of health care (including dental, sexual and mental health), technology to aid independence and safety. Plans need to be developed with participants being involved (with support if needed) and plans need to be fully implemented.
  6. The NDIS Quality and Safeguards Commission is unclear about the handling of reports of matters of concern. There is a gap in undertaking proactive visits to vet the performance of service providers.
  7. The NDIS Quality and Safeguards Commission needs to consider the risk factors associated with the use of unregistered providers of personal support, particularly for vulnerable participants.
  8. The Commission should explicitly require of all providers of personal support that there be at least two support workers for that individual (not necessarily at the same time) and that workers in the participant’s home have regular supervision.
  9. Regular health checks need to be available to all vulnerable NDIS participants. Where an NDIS participant is vulnerable, their NDIS plan should include coordination of their health care.
  10. The State Government needs to extend the scope of the Adult Safeguarding Unit to include all vulnerable adults earlier than 2022 as planned.
  11. DHS needs to revisit agreements with the Commission and the NDIA to ensure that relevant information on an individual worker that might affect their suitability to work with people with disabilities is shared with the screening unit in DHS quickly and fully.
  12. The commencement of the NDIS Quality and Safeguards Commissions on 1 July 2018 in South Australia has created issues with the scope of the Community Visitor Scheme.


  1. That the State Government communicate the matters raised in this report to the Commonwealth Government with special reference to Safeguarding Gaps 1 to 9, seeking a response on how these gaps can be addressed as soon as possible.
  2. That the State Government address the need for vulnerable NDIS participants to have regular health checks (Safeguarding Gap 9).
  3. That the State Government take measures to expand the role of the Adult Safeguarding Unit so that its scope includes vulnerable adults of any age (Safeguarding Gap 10).
  4. That DHS revisits the information sharing guidelines as they impact on screening of workers and, in particular, the availability of relevant information from the Commonwealth (Safeguarding Gap 11).
  5. That the State Government reaffirms the value of a Community Visitor Scheme as an additional safeguard for vulnerable participants, acting in conjunction with relevant Commonwealth legislation (Safeguarding Gap 12).

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