Following an investigation into the care provided to a young man with Down Syndrome and Autism at a community home, the Health and Disability Commissioner has referred one of the carers and the DHB to the Director of Proceedings for the purpose of deciding whether proceedings should be taken.

The Commissioner concluded that there was strong and compelling evidence that the carer physically and verbally abused the man, was aggressive when administering medication, and administered medication over and above that which was charted. Other behaviours of concern included allegations that the carer excluded the man's parents (and legal guardians) from his care, and fostered a culture of secrecy by telling staff "everything that happens in the house, stays in the house". With regards to the DHB, the Commissioner noted that all DHBs have clear responsibilities to provide safe, quality services; concerns about an employee's competence or conduct must be responded to in a decisive and timely manner; and "patient safety must be the paramount consideration". Here, the Commissioner found that the DHB failed to take appropriate action when concerns were raised, and that its poor response, including warning staff about making false allegations, led to the man being unnecessarily exposed to harm for an inexcusable period of time. Further, when concerns were again formally raised, the DHB undertook a paper-based review, and did not interview the man's parents or staff involved in his care: "it is difficult to justify a decision to conduct only a paper-based review in response to serious allegations of abuse of a vulnerable consumer... evidence supporting [the] concerns would have been available from staff if they had been interviewed... and supported to raise their concerns". The Commissioner also found that the DHB failed to provide the man's parents with adequate information, including information about the concerns raised and the DHB's response. 11HDC00877