'Failing miserably': coroner condemns conditions for licensed boarding house residents

The NSW Coroner has made findings in the inquest into the deaths of six residents of the licensed boarding house that, until recently, operated at 300 Livingstone Road, Marrickville. (We've mentioned the inquest previously, here and here.) The Coroner's conclusion:

If a society is judged by its treatment of its most vulnerable members, then ours is failing miserably.... There can be no question that the six who died who died at 300 Hostel between June 2009 and August 2010 were uncared for, poorly treated medically, and neglected.

We won't go into much detail about the medical aspects of the findings, about which, not surprisingly, the Coroner has a lot to say. It is enough for our purposes to note the Coroner's finding that the medical treatment of the residents was 'less than adequate':

There was little evidence of a co-ordinated approach between doctors and outside services or doctors and management. Reviews of medication, if they took place at all, were not properly recorded, and medical note-taking was negligible to the point of negligence.... Medication compliance amongst the patients was poor, and dangerously ill-supervised.... The need for the use of multiple anti-psychotic medication in the treatment of all the deceased was highly questionable.... I could not avoid seeing emerging a Dickensian picture of over-sedated people reduced to a state of inertia or lethargy in order to keep them quiet.

The Coroner also makes strong criticisms of the deceased residents' housing, their landlord, and the regulation of licensed boarding houses by NSW Ageing, Disability and Home Care (ADHC) – and these aspects of the findings we'll present in some detail.

The housing
First, in relation to the residents' housing, the Coroner finds:

The standards of hygiene and nutrition at the hostel were poor, facilities run down or not usable, and overall care sadly lacking. The weekend staff member had no training in first aid, and [landlord] Mr Young's explanation for this was not credible. Further, there were reports made of fire fighting safety equipment being outdated on one inspection and parts of the building posed high risks. In the last two years before closure, there was over 20 complaints recorded against 300 Hostel.

The complaints came from local support workers, one of whom described the boarding house to the Coroner as 'Third World':

There were blocked toilets, often only one working shower, no fans and unclean rooms. She [the support worker] also gave evidence that up to 25 people shared one bathroom including a toilet.... Ultimately, but only after many complaints, was a second toilet downstairs made available to clients as well as two extractor fans that were installed to assist with ventilation.

Another support worker gave evidence as to the state of the boarding house:

... It was dirty, had peeling paint, was ill-smelling, that some beds were without bedsheets, it contained dangerous stairs as well as no outside protection from the sun for residents. Care workers told her that some residents shared clothes, including underwear. 

This worker also stated that residents, lacking tenancy rights, were 'too frightened to complain'. Police officers who attended after the death of one of the residents also noted 'the lack of staff, the low morale of residents ('they were all outside and didn't speak to us'), and the run down state of the premises'.

For all this, residents each paid $290 per week. (That's about 85 per cent of the Disability Support Pension.)

The landlord
The licensee and landlord of the premises at the time was Mr Chris Young, formerly a psychiatric nurse and now, as we noted in our previous post, President of the NSW Property Owners Association. The Coroner summarises Mr Young's evidence to the inquest:

He disagreed with most criticisms of the Hostel and his management and was extremely defensive thorughout his examination. He claimed that most of the six deceased had constantly expressed how contented or happy they were at 300 Hostel.

If any criticism of the state of the premises was justified, then lack of funding was the reason.

Mr Young comes in for strong criticism by the Coroner, both for his evidence and his conduct. As noted above, the Coroner heard evidence that the weekend staff member had no first aid training (though she'd been employed for 11 years): Mr Young's explanation for this was, in the Coroner's words, 'absurd'. The Coroner also heard evidence that during the investigation of a resident's death, Mr Young attempted to dispose of a document relating to the resident's medical treatment, and had pressured his staff member and a resident to change their versions of events as stated to police. Mr Young's own evidence on these matters was, again in the Coroner's words, 'less than credible'. The Coroner says:

At the end of his testimony, it could not be said that he had given an impression of a compassionate, caring owner or boss whose only problem was lack of Departmental support of funding....

Despite Mr Young's assertions of compassion and sacrifice, the fact is that he and his wife were making a living from the boarding house and while undoubtedly hampered by lack of resources, appear to have been reducing services to residents to perhaps cut costs, and to have provided, at least in the last years, very little supervision or basic care to those most in need of it....

Mr Young and those providing medical services to the residents failed in their duty to address [residents' heath] problems.

The government department
Finally there's the part played by ADHC. The Coroner heard evidence from the officer responsible for the boarding house that he considered it 'top of those places dangerous to residents.' However:

He told the court that legal action had been considered when each inspection found serious problems although the legal advice given at that particular time to [ADHC] was that the laws governing compliance with the Licence obligations may not have been enforceable, and as a consequence prosecutions were not an option of first response.

We note here that the problem of unenforceable licences was first brought to the attention of the State Government in 1999 – and not resolved until amendments were made to the Youth and Community Services Regulation... 11 years later. This was too late for the residents of 300 Hostel. Observes the Coroner:

I do note that in the final months of operation at 300 Hostel, consideration was being given to withdrawing the licence. Unfortunately, that consideration was not acted upon so as to benefit the six residents who died in that time. It is significant that after 300 Hostel closed, the evidence shows that the remaining residents who were moved to alternative boarding houses all showed improvements in their health and demeanour.

The Coroner handed down her findings two days after the announcement by the NSW State Government that it would reform the boarding house sector, including through legislation for occupancy rights, a system of registration and standards for boarding houses, increased powers of inspections and increased penalties for non-compliance. The Coroner, without any further details of the Government's proposed reforms, could only 'endorse its intentions and concur with every proposal which improves the lives of our most vulnerable'.

As do we, and as do all those other advocates who have worked with boarding house residents and been dismayed by the neglect they've suffered, both from landlords and from past governments.