Assessment 4: Case Study for Becoming a Reflective Practitioner

This case study about Gabriel. Inclusion Australia sent it to the Disability Royal Commission as part of
their inquiry into abuse, neglect and exploitation of people with disability. You can see the full
document about the experiences of people in group homes by going to the link in the reference at
the end of this document.

Case Study: He died alone with $100,000 in the bank 

This is the story of a man with Down syndrome who died alone at the
height of the COVID-19 pandemic.  

Gabriel was 60. He had Down syndrome and, after being relinquished
as an infant, grew up in Kew Cottagesa.  

When the institution closed, Gabriel was moved into a group home in
Melbourne’s suburbs.  

In early 2020, during Victoria’s first COVID-19 lockdown, VALID

received a telephone call from a support coordinator. The support
coordinator said Gabriel needed an advocate.  

According to the support coordinator, Gabriel had fallen in the group

home and broken his hip. He had surgery, but the hospital
rehabilitation program — which was not geared to the needs of a
person with an intellectual disability — had failed. Gabriel’s hip joint
had frozen and he could only be moved with a hoist. His group home
could not accommodate a hoist, so he was effectively homeless in
hospital. 

During the pandemic, Gabriel was moved from hospital to a

transitional aged care facility to wait for another placement.  

The group home was legally required (Residential Tenancies Act 1997)
to notify the Office of the Public Advocate of Gabriel’s changed living
arrangements but failed to lodge a Notice to Vacate. Instead, the
hospital, group home and transitional aged care facility debated what
to do with Gabriel. The support worker told VALID that there were not
any decision-making supports — Gabriel did not have a say in his own
future.  

The support coordinator told VALID that Gabriel had spent four
months in hospital and the aged care facility and was missing the
other residents of the group home, who he had known since
childhood. 

‘He was crying the whole time he was there. He was distressed and
afraid and calling out for people from his house who weren’t there,’ a
VALID advocate said.  
‘The support coordinator said, “Can you please help? I don’t know
what to do. They’re all pushing for aged care. The provider’s for it, the
hospital’s for it. I think they’re going to sign off on it. I don’t think it’s
right. I don’t actually think this is what should happen.”’ 

Gabriel died the day after the support coordinator called VALID.  

When a VALID advocate asked the aged care facility why an

otherwise-healthy man suddenly died she was told ‘it was his time to
go’. 

There was no investigation into Gabriel’s cause of death. VALID did

not have the authority to request a coronial inquest.   

Shortly after Gabriel’s death, VALID was told that he died with more
than $100,000 in savings – money saved on his behalf by a state-
appointed administrator over six decades in the disability system. 

That money could have been invested to aid Gabriel’s rehabilitation or

secure housing of his choice. But the money wasn’t spent. Nothing
was done.  

Gabriel died afraid and alone.

a
Kew Cottages was an institution for people with disabilities in Kew, Melbourne. It ceased to operate
as an institution in 2008, when all residents were moved into homes in the community, mostly in the
form of group homes.

Reference

Inclusion Australia. (not dated). Group homes. https://www.inclusionaustralia.org.au/story/group-

homes/