Incidents of "unexplained" injuries, clients going missing and staff stretched to the limit at a major disability provider have been under the spotlight at the disability royal commission.
The incidents occurred at a time when the company expanded operations and more than tripled its revenue.
A five-day hearing has examined the roles and responsibilities of the Australian Foundation for Disability — also known as Afford — to safeguard participants in their day programs from violence, abuse and neglect.
It focused on the Mount Druitt day program and heard from parents of participants and former staff about their experiences between 2018 and 2021.
Daniel Nuumaalii, a support worker at the day program, was jailed last year after pleading guilty to recording and sharing intimate images of Afford participants with "high support needs".
The inquiry heard there were other incidents under investigation, including an allegation by a participant "he was hosed down like a dog after soiling himself".
The royal commission could not fully discuss the case of 20-year-old Merna Aprem, who died while living in Afford's supported accommodation, as a coronial inquiry and legal proceedings are continuing.
Investigation 'prompted' by ABC story
One of the country's longest-running disability services providers, Afford serviced 898 clients in 2016/17 and grew to 6,281 in 2021, the inquiry heard.
The royal commission was told that Afford's revenue increased from $51.8 million in the financial year 2016/17 to $145.6 million in the financial year to 2021.
The charity runs services across NSW, Victoria, Queensland, Western Australia and South Australia.
Samantha Taylor from the NDIS Quality and Safeguards Commission gave evidence that there was an "open investigation" into the "alleged misuse of NDIS funding by Afford" and "possible breaches of the NDIS Act."
Ms Taylor said matters under investigation included that Afford's executives "created a culture of excessive spending for staff and employees on matters unrelated to the care of participants" and money was "spent on extravagant functions."
The hearing was told the investigation was "prompted" by a story on the ABC's 7.30 program in July 2021.
The royal commission was told the ABC's story also prompted Afford to report an incident to the NDIS Quality and Safeguards Commission of a client who had been sent home from respite accommodation and later taken to hospital, after being fed solid food that became "stuck in his airway."
The man had a "mealtime management plan which stipulated he couldn't eat solid food" and staff were issued "formal warning letters" by Afford.
The inquiry was told that since July 2018, there were 969 incidents where people with disability in Afford's care hadn't been given their medication.
First Nations man filmed naked
Three women gave evidence, using pseudonyms, about the experiences of their adult sons at the Mount Druitt day program.
'Lily' told of how her 27-year-old son 'Simon', who lives with ADHD, autism and epilepsy, attended the program between 2013 and 2020.
Lily said the day program became "glorified babysitting" between 2019 and 2020, because the staff didn't have adequate training.
The royal commission was told Simon came home with an "unexplained black eye", and Lily "never got an answer" about what happened.
Another parent, 'Sally', spoke about the "shock" of being told by police that her 24-year-old son, 'Jason', had been abused by Nuumaalii in 2019.
Images of clients were found on Nuumaalii's phone showing several people with disability "naked in the shower, who were using the toilet or having their incontinence aids changed".
The royal commission was told there was no evidence Afford was aware of the abuse prior to it being uncovered by the police.
Jason, who identifies as a First Nations man and lives with intellectual disability and autism, was filmed by Nuumaalii in the shower and at the day program at Mount Druitt.
'Suzie' gave evidence about her son 'Toby' who was also a victim of Nuumaalii.
Nuumaalii filmed Toby, who lives with Down syndrome, "semi-naked in a public toilet."
Suzie said Toby had no awareness of road safety or "stranger danger."
She told the hearing that Afford took Toby and a group of clients to Bondi Beach in 2018 and he "absconded" and was lost for about an hour.
Five months later, Toby was "lost again" at Mount Druitt whilst in Afford's care and was found by police in the middle of a main road.
Former executive speaks out
The statement of a whistleblower who was a senior executive at Afford between 2015 and 2020 was read to the inquiry.
Using the pseudonym 'Rachel', she detailed her concerns around Afford's compliance, safety and quality of services.
She said the former CEO would become "aggressive" if senior managers were not meeting targets for "filling beds in group homes."
Rachel said staff received commissions based on the number of new clients they were able to sign-up and the amount was "based on the size of the NDIS packages of those clients."
When she raised her issues with the former CEO, he yelled at Rachel and told her to "grow a backbone", the inquiry heard.
Under whistleblower protections, Rachel wrote a five-page report about her concerns and sent it to a board member, before resigning after feeling "targeted and isolated."
'Dianne', who spent two years working at the Mount Druitt centre, told the hearing there was a "rapid increase" in the number of participants.
She asked Afford to restrict the number of clients because it was becoming "dangerous."
Dianne said clients were left "vulnerable and open" because they were seen as "dollar figures."
Risk management 'fundamentally deficient'
Afford appointed Joanne Toohey as its CEO in October 2021, and she gave evidence for two days alongside the chair of the Afford board, Mike Allen.
Both gave the royal commission detailed information about reforms and changes to Afford's policies and procedures since Ms Toohey had taken on the new role.
On Thursday, Ms Toohey was forced to apologise to the royal commission for a media statement that Afford distributed earlier in the week which offered her "deepest sympathies" to the witnesses and their families for the "failings and heartache caused."
Senior counsel assisting, Pat Griffin, said Ms Toohey had put the "organisation ahead of the needs of the individual" by issuing the statement.
He said the commission's counselling section had been contacted by a "concerned" family member.
"I'm truly sorry for the impact it's had," Ms Toohey said, referring to the statement.
Chair of the royal commission, Ronald Sackville, said if Afford had wanted to make an apology, then it should have discussed this with the legal team so as to not make matters "worse" for the people "traumatised" by the events.
But Afford did not use the hearing to apologise to the clients or their families for the incidents of abuse and neglect whilst in their care.
Under questioning, Mr Allen, a board member since 2015, admitted that in "hindsight" there was more the board should have done.
He agreed with Mr Griffin that Afford's risk management had been "fundamentally deficient."
Mr Allen said Afford's board needed to "very quickly" look at a written apology and "redress" for the victims of abuse.
