We acted for the family of 20-year-old Hunter man Cameron de Vries during the five-day coronial inquest into his tragic drowning death.
The inquest, held in February 2025 at Lidcombe Coroners Court in Sydney, examined whether those responsible for his care properly managed his clinical and healthcare needs when he drowned in August 2019 after allegedly being placed in the bath by a disability support worker.
Cameron, a National Disability Insurance Scheme (NDIS) participant, lived with severe autism, a global developmental delay, and a significant intellectual disability, and required intensive supervision and care.
NDIS under scrutiny amid crisis of neglect and poor conditions
At the time of his death, Cameron was living in purpose-built Supported Independent Living (SIL) accommodation, managed by a registered NDIS provider, Interaction Disability Services (IDS), and supported by his parents.
The inquest examined whether his care team adequately managed the risks to Cameron’s health and whether the staff had the necessary competency and training to support him effectively.
Our principal, Catherine Henry, told the Newcastle Herald the inquest comes at a time when the NDIS is facing increasing scrutiny amid numerous disturbing reports.
“More than a decade since its introduction, reports of neglect and squalid conditions in disability housing are common,” she said.
The Disability Royal Commission, Australia’s longest-running inquiry, made 222 recommendations for reform, with the federal government accepting just 17 of those recommendations.
Cameron de Vries’ family’s pursuit of justice and reform
Cameron’s parents are committed to seeking justice, using the inquest to advocate for reforms aimed at improving care and safety within the NDIS.
“The family is determined to see that Cameron’s death is not in vain,” said Catherine. Their objective is to help prevent similar tragedies and ensure safer, more dignified care for people with disabilities—especially NDIS participants.
The Coroner’s findings
The Coroner’s report, released on 28 February 2025, found that Cameron died by drowning while unsupervised, with the incident precipitated by a seizure. Cameron greatly enjoyed water play and often wanted to spend time in the bath, even after showering. Due to his disability, he was especially vulnerable and required close supervision while bathing.
The Coroner found that risk management and safety plans were inadequate and inappropriate. These processes were confusing, inconsistent and lacked detail. Furthermore, the Coroner found that the risk management and safety plans were not sufficiently disclosed nor effectively communicated to the staff responsible for Cameron’s care.
Guidance given to the provider’s staff was vague and inadequate. The provider’s (IDS) records were inadequate and inaccurate and included “ad hoc and inaccurate entry of daily progress notes and failure to adequately document medication”. At least one of the carer’s notes and evidence at the inquest were problematic and possibly fabricated. The Coroner was “unable to make a positive finding that Cameron was checked while he was in the bath” during the critical period.
The Coroner’s recommendations
The Coroner recommended that the provider (IDS):
- Conduct an audit of progress note documentation for participants at the group home, including:
i. A review of behavioural support documentation to ensure clear guidance to staff about risks and strategies to manage behaviour;
ii. The use of more precise language than terms such as ‘spot-checks’ and ‘periodically’ in relation to monitoring. - Develop an updated version of the Client Personal Profile that sets out participants’ support needs and response strategies, and accurately reflects other critical support documents.
- Review medication administration practices.
Ensuring safe, dignified care for NDIS participants
Cameron’s death highlights the critical need for improved training, oversight and regulation within disability care services. At Catherine Henry Lawyers, we remain committed to advocating for better systems to ensure individuals like Cameron receive the respect and care they deserve.
Contact Catherine Henry Lawyers for expert help with Coronial Inquests
If you need advice or representation regarding a coronial inquest, our expert health and medical lawyers have extensive experience in this area. To find out how we can assist you, call 1800 874 949 or complete the contact form below.
