When Duty Fails: Court Holds NDIS Provider to Account for Tragic Death of Participant

When Duty Fails: Court Holds NDIS Provider to Account for Tragic Death of Participant

On 10 October 2025, the Federal Court of Australia (the Court) handed down its decision in relation to the tragic death of a NDIS participant, Mr Ankur Gupta (Mr Gupta). A $2.2 million penalty was imposed against Aurora Community Care Pty Ltd (Aurora). The full decision can be found here (Decision).

Aurora was found to have breached the National Disability Insurance Scheme (NDIS) Act by engaging in unauthorised restrictive practices and failing to provide safe and appropriate supports. This Decision serves as a clear message that providers who fail to protect the rights, dignity, and wellbeing of participants will face serious legal and reputational consequences. NDIS providers must not only act in compliance with the NDIS Code of Conduct but also uphold a robust duty of care to participants, especially when restrictive practices and behavioural support are involved.

Background

Aurora operated as a NDIS-registered provider, offering services to participants with complex behavioural needs. Mr Gupta was a NDIS participant with an intellectual disability, who was killed after being struck by a car near his Supported Independent Living home in Queensland. Aurora was responsible for providing full time 2-on-1 supports (where two support workers are assigned to one participant) to Mr Gupta and were aware he was at high risk of wandering off. Mr Gupta was not being monitored or supervised when he left his home, with one support worker asleep and the other in another room.

Between August 2021 and February 2023, Aurora staff also used restrictive practices, including physical restraint and seclusion, against Mr Gupta, without authorisation and without appropriate oversight. Evidence showed that these practices were used repeatedly, often in response to behaviours that did not justify such measures. The Court found that Aurora failed to ensure its staff were trained and supervised in behavioural support. Aurora lacked clear risk assessment and incident management systems and ignored repeated warning signs of escalating harm to Mr Gupta.

The NDIS Quality and Safeguards Commission (the Commission) launched proceedings, alleging Aurora had breached multiple provisions of the NDIS Act 2013, including its obligations under sections 73Z and 73P regarding the use of restrictive practices and participant safety.

What the Court Found

The Court found that Aurora had engaged in systemic, prolonged breaches that represented a “serious departure” from its duty of care to participants. The Court noted that Aurora’s leadership failed to implement adequate controls to protect vulnerable individuals, even after being made aware of compliance concerns. Their “reactive and inconsistent” approach was described as reflecting a disregard for participant’s safety and dignity. In determining the penalty, the Court considered the following:

• The vulnerability of the participant and the harm caused;
• The provider’s lack of governance oversight;
• The need for deterrence, both specific and general, across the NDIS sector; and
• Aurora’s post-incident cooperation, including attempts to improve training and
  policies.

Aurora was fined $1.2 million and ordered to pay the Commission’s costs, with the Court emphasising that “the community expects NDIS providers to meet the highest standards of care and accountability.” In addition, the Court ordered a 10-year ban on Aurora’s director, Mr Mohamed Issak, from involvement in certain NDIS activities, and a two-year ban on the two support workers involved.

Why Duty of Care Matters Under the NDIS

NDIS providers hold a non-delegable duty of care to participants. This means the obligation to ensure participants’ safety cannot be outsourced or ignored, even when day-to-day care is delivered by support workers.

The duty of care sits alongside, and is reinforced by, the NDIS Code of Conduct and the NDIS (Restrictive Practices and Behaviour Support) Rules 2018, which require providers to:

• Uphold participants’ human rights and dignity;
• Use restrictive practices only as a last resort and with proper authorisation;
• Ensure all staff are trained and supported to manage behaviours safely; and
• Maintain governance systems that prevent, detect, and respond to risk.

Lessons for NDIS Providers

This Decision demonstrates that failing to meet these standards can amount not only to a regulatory breach, but to a fundamental failure of duty and trust which can result in tragic outcomes. The Decision serves as a critical reminder for NDIS providers of all sizes that:

• Governance and oversight are non-negotiable. Boards and senior managers must actively monitor service delivery risks. Duty of care breaches often reflect leadership failures, not just frontline mistakes.
• Restrictive practices must be lawful and documented. Any use of restraint, seclusion, or other restrictive measures must comply with the NDIS Behaviour Support Rules. Regular audits and clear authorisation pathways are essential.
• Training and supervision are core safeguards. Staff must be competent to manage complex behaviours safely. Ongoing supervision and debriefing reduce risk and build accountability.
• Incident management and early reporting prevent escalation. Providers should
  ensure that staff can report incidents confidentially and that management acts
  promptly to address emerging risks.
• Culture counts. A safeguarding culture means prioritising participants’ dignity over convenience. Organisations must encourage reflection, transparency, and ethical decision-making.

How Can Safe Space Legal Help?

The team at Safe Space Legal has extensive experience working with organisations in the disability sector, to support and strengthen their safeguarding practices and ensure organisations are meeting their legal obligations when working with people with disability. We work with organisations across Australia and frequently conduct independent
safeguarding investigations.

Safe Space Legal offers holistic safeguarding services including:

• Developing safeguarding policies, procedures and complaints-handling processes;
• Delivering safeguarding training to ensure organisations are aware of their obligations and sector-specific requirements;
• Conducting trauma-informed specialist safeguarding investigations into allegations of violence, abuse, neglect and exploitation in the disability sector;
• Providing expert advice on safeguarding compliance and systemic issues;
• Conducting root cause analyses of critical incidents and crisis management;
• Providing sound legal advice on risk mitigation; and
• Completing policy and implementation audits to ensure compliance with legislative obligations.

Contact office@safespacelegal.com.au or call (03) 9124 7321 to organise a complementary discussion in relation to your organisation’s safeguarding needs.