NDIS Commission Takes Legal Action Following Death of Participant: Learnings for NDIS Providers

NDIS Commission Takes Legal Action Following Death of Participant: Learnings for NDIS Providers

The NDIS Quality and Safeguards Commission (Commission) has commenced proceedings in
the Federal Court of Australia (Court) against Amicus Community Services Limited (Amicus)
and a former support worker following the death of a NDIS participant. While the findings are yet
to be handed down by the Court, the proceedings highlight the importance of worker
competence, training, supervision, risk management, and the systems NDIS providers must
have in place to keep participants safe.

Background

On 21 September 2026, the Commission announced that it had commenced legal proceedings
against Amicus and former support worker, Georgina Knox (Ms Knox), following the death of
NDIS participant, Joanne Keogh (Ms Keogh).

The Commission has alleged that between September 2020 and May 2021, Amicus failed to
ensure that workers providing supports to Ms Keogh had the necessary qualifications, training
and experience. It has also been alleged that, on a number of occasions, support was not
provided to Ms Keogh, placing her at significant risk of harm.

The proceedings relate to events surrounding Ms Keogh’s death on 6 May 2021. Ms Keogh
suffered an epileptic seizure, fell from her bed and stopped breathing. The Commission alleges
that Ms Knox failed to respond to an alarm triggered by the seizure and fall and failed to check
on Ms Keogh at least hourly during the night. Ms Keogh was subsequently discovered
unresponsive by another support worker approximately eight hours later.

These allegations are before the Court. There has not yet been a judgment determining whether
Amicus or Ms Knox contravened the relevant laws or standards. The proceedings follow a
lengthy investigation by the Commission. The Commission has also stated that Ms Knox was
permanently banned from involvement in the provision of supports or services to NDIS
participants in May 2023.

The Commission is seeking financial penalties against Amicus in relation to alleged breaches of
the NDIS Practice Standards (Standards) and against Ms Knox in relation to the alleged failure
to comply with the NDIS Code of Conduct (Code).

What is the Relevant Legal Framework?

The NDIS operates within a regulatory framework designed to protect the rights, safety and
wellbeing of people with disability.

The Code applies to NDIS providers and people employed or otherwise engaged by providers.
Among other obligations, the Code requires persons covered by the Code to provide supports
and services in a safe and competent manner, with care and skill.

It also requires workers and providers to promptly raise and respond to concerns that may affect
the quality and safety of the delivery of supports and to take reasonable steps to prevent and
respond to violence, exploitation, neglect and abuse.

For registered providers, the Standards establish requirements in relation to areas including
governance, risk management, incident management, human resource management, the
provision of supports and safe environments.

The Human Resource Management requirements are particularly relevant to the allegations in
the Amicus proceedings. The Standards provide that participants’ support needs are to be met
by workers who are competent in their roles and have relevant qualifications, expertise and
experience.

This is more than simply checking whether a worker has completed an induction. Providers
must have systems for identifying the skills and knowledge required for different roles,
maintaining records of qualifications and experience, providing appropriate induction and
training, and ensuring workers receive supervision, support and resources appropriate to the
complexity of the supports they deliver.

The Commission’s guidance also emphasises that providers have a responsibility to ensure
workers have the necessary training, competence and qualifications to deliver supports and
services.

Competence is Not Just a Recruitment Issue

An important lesson from these proceedings is that workforce capability should not be treated as something that is assessed once, when a worker is hired. A worker may have appropriate qualifications but still require additional training, supervision or support before undertaking particular duties.

Similarly, an organisation may have policies requiring workers to undertake certain checks or training, but that does not necessarily mean the organisation can demonstrate that workers are actually competent to perform the tasks they have been assigned.

For organisations, this raises practical questions:

• What skills and competencies are required for each role?
• Are those requirements documented?
• Have workers been appropriately trained before undertaking higher-risk duties?
• Are qualifications, experience, training and competency records current?
• Is refresher training provided where required?
• Are workers appropriately supervised?
• Does the organisation know when a worker may need additional support or supervision?
• Are workers working within the scope of their training and experience?

Risk Management Must Operate in Practice

The Standards require providers to identify and manage risks associated with the delivery of supports. A risk management system must therefore be effective in practice. Organisations need to understand the individual risks associated with each participant and ensure that those
risks are reflected in support planning, worker training, staffing arrangements and day-to-day
practice.

For example, where a participant has a known medical condition that may require an urgent response, an organisation should consider whether workers understand:

• what the risk is;
• what warning signs they need to recognise;
• what action they are expected to take;
• when emergency assistance should be sought;
• who must be contacted;
• what equipment or technology is being used;
• whether workers have been trained and assessed as competent; and
• whether the arrangements are regularly reviewed.

Incident Management

The Commission’s incident management requirements are also important. An incident is not limited to an event where someone has already suffered serious harm. The Commission describes an incident as an act, omission, event or circumstance that has, or could have, caused harm to a person with disability.

Providers should have systems for identifying, assessing, recording, managing and resolving incidents. Importantly, incident management should also be about learning.

The Commission expects providers to examine the causes, responses and outcomes of incidents and use that information to improve their systems and practices. This means an organisation should not simply ask, “What happened”; It should also ask, “Why did it happen, and what needs to change so it is less likely to happen again?”

That may involve examining staffing arrangements, training, supervision, communication, policies, technology, escalation procedures, documentation and organisational culture.

A written procedure is only one part of the safeguard. The organisation must also consider whether workers understand and can implement the procedure when it matters.

Deaths and Other Serious Incidents

The NDIS regulatory framework also contains specific reporting requirements. For registered NDIS providers, the death of a person with disability that occurs in connection with the delivery
of NDIS supports or services is a reportable incident. The Commission states that a provider must notify them of a participant’s death within 24 hours of becoming aware of the incident.

Providers do not need to establish the cause of death before notifying the Commission where
the death is connected with the provision of NDIS supports or services. This illustrates why
organisations need clear incident reporting and escalation procedures before an incident
occurs.

Workers should understand who they report to, what information needs to be recorded, when an
incident must be escalated and who has responsibility for notifying the Commission and other
relevant authorities.

The Bigger Safeguarding Lesson

The Amicus proceedings are yet to be determined, but the allegations highlight a broader issue for organisations providing services to people with disability. Safeguarding is not achieved through one policy, one training session or one recruitment check. It is a system.

That system needs to connect recruitment, worker screening, qualifications, competency, induction, training, supervision, participant-specific risk assessments, support planning, incident management, complaints handling and organisational governance. There should also be mechanisms for identifying when something is not working.

A missed shift, a worker failing to follow a support plan, an unexplained injury, repeated documentation gaps or a worker expressing uncertainty about how to respond to a participant’s needs may each provide information about a broader risk.

Small warning signs should not necessarily be treated as isolated administrative problems. They
can provide an opportunity for an organisation to identify and address a systemic issue before a
participant is seriously harmed.

What Does This Mean For Organisations?

For NDIS providers and other organisations supporting people with disability, the proceedings provide an opportunity to review whether safeguarding systems work in practice.

Organisations should consider conducting a structured review of:

• Workforce capability – Are workers appropriately qualified, trained, experienced and
  competent for the supports they provide?
• Supervision – Are workers receiving supervision proportionate to the complexity and risk
  of their work?
• Participant risk – Are individual risks identified, documented, communicated and regularly
  reviewed?
• Emergency response – Do workers know what to do when a participant experiences a
  medical emergency or other serious event?
• Incident management – Can workers recognise, report and escalate incidents and near misses?
• Governance – Does leadership receive meaningful information about incidents,
  complaints, risks and emerging patterns?
• Continuous improvement – When something goes wrong, does the organisation identify
  the underlying causes and make measurable changes?

These questions can help organisations move beyond a compliance-focused approach towards
a safeguarding framework that is actively and effectively implemented at every level of the
organisation.

How Can Safe Space Legal Help?

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

Our motto is: ‘prevent, comply, respond’. We work across the complete safeguarding cycle and help organisations identify risks before harm occurs, understand and meet their obligations, and respond appropriately when concerns or incidents arise.

Our services include:

• 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.