Two-and-a-half years after Merna Aprem was found drowned in the bath of her NDIS-funded care home in Sydney, the industry watchdog has announced a historic lawsuit accusing the provider of a litany of failures.
The lawsuit is the first of its kind from the Quality and Safeguards Commission, which formed as part of the National Disability Insurance Scheme in July 2018.
Ms Aprem - who had epilepsy and autism - had moved into Woodbine residential home two months before she was found face down and surrounded by vomit in the bath on May 23, 2019.
Following "extensive" investigations, the federal agency on Monday announced it is suing the Australian Foundation for Disability (Afford), which ran the home, over Ms Aprem's "tragic" death.
In documents filed in the Federal Court, the commission alleges the company failed in its obligations to support Ms Aprem in a safe and competent manner, with care and skill.
That left the 20-year-old's safety at "real and significant risk".
"The Commissioner further contends that Ms Aprem's death may have been caused or contributed to thereby," it reads.
Two support workers were at the home on the evening of Ms Aprem's death, according to the claim tendered to the court.
Neither had worked there before, and neither had the benefit of a "buddy shift" with more experienced staff to prepare them for taking care of the home's four residents.
Neither were aware that Ms Aprem suffered from epilepsy.
She was left alone in the bath that evening, with the door ajar. But when one of the women returned to check on her, the door was locked and Ms Aprem wasn't responding.
The pair broke into the bathroom, using a kitchen knife to unscrew the handle and finding Ms Aprem unconscious with her mouth and nose submerged, the documents before the court say.
Paramedics - who were only called more than 20 minutes after the carer found the door locked - were unable to revive Ms Aprem and she died at the scene.
Notably, of three documents the home was required to have outlining Ms Aprem's needs, one didn't exist and the other two were incomplete, the commission claims.
Among other omissions, a section of Ms Aprem's incomplete epilepsy management plan requiring the identification of strategies to manage the risk of bathing or showering was left blank.
The commission alleges Afford failed to ensure Ms Aprem's diagnoses and support needs were adequately documented in client records or ensure that the support workers were made aware them.
It also failed to implement measures to protect Ms Aprem whilst bathing, including ensuring staff had access to her bathroom.
NDIS providers have very clear obligations, Acting NDIS Commissioner Samantha Taylor said, and providers who don't meet them will be weeded out by the commission.
"Failures, like those alleged by the NDIS Commission in these proceedings, will not be tolerated," she said.
Australian Associated Press