The Deputy Health and Disability Commissioner has found IDEA Services failed to respond appropriately to escalating abuse concerns raised about a supported living flat, and then mishandled the woman’s formal complaint.

In a decision released today, Deputy Commissioner Rose Wall found IDEA breached the Code of Health and Disability Services Consumers’ Rights by not facilitating a “fair, simple, speedy and efficient” resolution of the woman’s complaint. The service manager responsible for the flat, identified as Ms B, was found to have breached the Code for not managing incident reports and risks in line with IDEA’s own policies. The area manager involved, Ms D, was not found in breach.

The woman, Ms A, who has an intellectual disability, lived with three male flatmates and received IDEA support under a supported living agreement between YearB and YearH. During a period of nationwide public health restrictions, face‑to‑face support was reduced and moved online.

From Month4 to Month6 of YearG, support workers filed a series of incident reports and emails about tensions and alleged behaviour in the flat, including shouting, bullying and control over Ms A. Records include a disclosure that Mr C tried to force Ms A to give him money and threatened to tickle her if she refused, and a separate disclosure to a support worker that Mr C had touched Ms A’s breasts during the restrictions and that they had sex the previous year without her consent. In one report, another flatmate alleged a resident would remove clothing and ask others, including Ms A, to massage him.

An IDEA internal investigation later found that 11 of 14 incident reports logged during this period were left “awaiting update from manager” and were not followed up adequately or in a timely manner. It said lack of action from Ms B led staff to escalate directly to the area manager, Ms D, and described support workers as feeling burdened and desperate for guidance. Some incidents were not closed for many months; one marked “extreme” risk was closed 10 months later.

Ms A told IDEA she had been sexually assaulted by Mr C two years before the events in question; IDEA said it knew only of a physical altercation in Month3 YearE. During the restrictions, IDEA did not include Ms A in the regular status reporting it was providing for other clients, and it did not complete a welfare checklist for her, saying she had been assessed by NASC as capable of living independently and did not require additional monitoring. Independent clinical advice to the HDC said failing to apply these safeguards represented a moderate departure from accepted practice given the known history between residents and the unusual pressures of lockdown living.

When staff concerns escalated in early Month6 YearG, Ms A was supported to stay with a friend, and Ms D was informed. Ms D told the HDC she worked to relocate Ms A that day, attempted to contact Ms B (who was on periods of sick leave), escalated the matter internally, ensured Ms A saw a doctor and thanked staff for their support. Police were notified in early Month7, but took no further action, citing the severe intellectual disabilities of those involved and concerns about their ability to participate in court.

Ms A made a formal complaint to IDEA in early Month8 YearG. It was not acknowledged or responded to until late Month8, and the response apologised but concluded there was insufficient information for IDEA to have intervened beyond changing Ms A’s accommodation. The HDC said there was ample evidence from Month5 that the environment had become dangerous for Ms A’s health and wellbeing, as confirmed by IDEA’s own internal investigation completed the previous month.

The Deputy Commissioner found IDEA breached Right 10(3) of the Code by failing to acknowledge or respond to Ms A’s complaint in a timely manner and by not recognising shortcomings already identified internally. Ms B’s handling of incident reports and escalation obligations was found to be a moderate departure from accepted standards, breaching Right 4(2). The decision noted conflicting accounts about Ms B’s sick leave but found she was aware of escalating concerns from as early as Month5 and did not act in line with IDEA’s incident policy. Ms D’s response in early Month6 was considered not swift enough, but mitigating factors were recognised, and no breach was found.

IDEA told the HDC it broadly accepts the findings and recommendations, but it does not consider service changes are needed. It said it had commissioned an independent review of Supported Living in the region which reported positive feedback from people supported. IDEA also said there were no broad Ministry of Health reporting requirements at the time and that NASC — not IDEA — assessed Ms A’s independence and support needs. The Deputy Commissioner said IDEA, as the day‑to‑day provider, remained responsible for assessing and managing Ms A’s specific risks.

Ms A’s representative said she viewed the recommendations as “good” and connected the outcome with her hope that what happened to her would not happen to others.

The HDC has recommended IDEA and Ms B provide written apologies to Ms A within three weeks; that IDEA use an anonymised version of the report to train staff on creating and updating incident reports; and that IDEA audit six months of incident reporting to confirm it meets policy, with results and any remedial action due within six months. The Deputy Commissioner also encouraged IDEA to review workloads for service and area managers. As Ms B no longer works for IDEA, she is to provide a written reflection to the HDC within three months.

A copy of the anonymised report will go to HealthCert at the Ministry of Health, Disability Support Services, and the Ministry of Social Development, and will be published on the HDC website.

An addendum notes Ms B did not comply with the Deputy Commissioner’s recommendations.