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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.

Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

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From DHS Incident Reports:

The writer took Peter to Moonee Ponds for an access visit. Peter
was telling his family members about the bullying he is suffering from
co- client John at the unit. During this conversation, Fred Smith (the
partner of Peters cousin) made threats to harm John. He said: Im
going to come to Oakleigh and stab that kid. Ill get him and kill him for
you. No one will even know it was me".
______
Andrew went into the unit and threw the Christmas tree and other
items around the unit and smashed glass against the unit wall and
threw a two litre bottle of milk on the floor. When asked why he was
behaving this way he said because he felt like it. Andrew continued
to escalate and threw a glass at the office door and it shattered
immediately. Staff decided to disengage and stay in the office at this
stage as he was clearly agitated and it was not safe to be out on the
floor.
Andrew then tipped over the entire refrigerator making a huge mess
with yoghurt and other food that was in the fridge. Staff contacted 000
and police attended. Once the police left, staff proceeded to clean up
the mess. The floor was very slippery and Jenny slipped in some
yoghurt and fell onto one arm trying to break her fall.
______

As Writer was finishing up the night, I heard a noise coming from


ABs room at 11:30pm and it did not sound right, so I went to the
office door to see what was going on and AB and BC were fighting
and very violently punching each other in the face for about five
minutes...

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Royal Commission into Institutionalised Child Sexual Abuse


Submission Ref. Number: R015162
Submission by Dr Philip Alan West
BA (Hons.), Dip. Ed., Grad. Cert. Immigration Law, Ph.D.
Significant Public Achievement:
Founder and establishment CEO:
The Alannah & Madeline Foundation
Founder and President: P.E.A.C.E. Inc.
(Peace through Arts and Creative Empowerment)

Recognition:
Winner of the Pauline Toner Award for Community Service (conferred by La Trobe
University) for my role in establishing the Alannah and Madeline Foundation
Joint Winner: UNDP Humanising Development Global Photographic Competition, 2010,
for the photo As Children Should Be taken in Kalimantan, Indonesia

____________________________________________________________
SUMMARY of FINDINGS
I submit that Out of Home (Residential) Care operates as institutionalised Statesanctioned abuse & neglect - not care - for thousands of vulnerable,
traumatised young people.
_____________________________________________________________

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

This is an article that appeared a few days after I completed this report. I have added it here as it
very much relates to this issue and my recommendations.

Magistrate says addicted children


should go to rehab
Date

April 9, 2015

Drug-addicted teenagers should be required to live in rehabilitation centres, with the current system failing
to help many of the state's most vulnerable get clean, a magistrate says.
Children's Court Magistrate Jennifer Bowles realised how little she could do to help such children when
confronted by the mother of teenager Greg,* who had tried and failed six times to complete a voluntary
drug treatment program. In open court, the mother asked the Magistrate some years ago: "What can you
do? I am watching my son die before my eyes."
"And all I had after the voluntary de-tox had not worked was 'We can detain him in custody'. And when it's
a health issue, it's not a punitive response that we'd like," Ms Bowles said.
Last year, she travelled on a Churchill fellowship to Sweden, where children can be ordered to live in
secure homes to treat their drug problems and mental illnesses.
Ms Bowles said such therapeutic facilities were urgently needed in Victoria for children aged about 13 to
17 who were often abused or, like Greg, self-medicating their mental illnesses. "We'd like to be able to
have somewhere to treat (children like Greg) with specialists ... to try to work out the underlying issues for
why young people are using substances."
In her fellowship report 'What can be done?' she said: "These young people will lead the most damaged
lives and be the most resource-intensive unless their needs can be addressed now."
Currently, magistrates can order children to attend treatment for drug and alcohol problems and mental
health issues, which can include weekly counseling sessions. But because these rehabilitation facilities
are voluntary, children cannot be compelled to attend them, and often struggle to do so.
Ideally, Ms Bowles said that children in different age groups would be separated, with specialist help to
move back into the community as soon as possible. The court would also monitor their treatment to
protect them from potential abuse while they were inside.
While the magistrate stressed that she was not critical of voluntary facilities, without "radical" change, she
said the system risked perpetuating harm. Almost 90 per cent of young people in custody have a history
of alcohol and/or drug misuse and 59 per cent have a history of being in child protection.
"We have to do something to stop this cycle because some of my colleagues ... have seen nearly three
generations of parents coming through our court," she said.
Ms Bowles understood the community's reluctance to contain children but said this would be a last resort
for those who could not benefit from voluntary treatment: "Their lives are really tragic and they're not only
hurting their own health, they're limiting their options for the rest of their futures. I really worry about where
they're going to end up."
A spokeswoman for Families and Children Minister Jenny Mikakos said: "The Minister will soon be
meeting with Magistrate Bowles and looks forward to discussing her report and recommendations then."

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Table of Contents

1. Personal background:

Page

- History of my work in Out of Home Care


- Professional Preface re this submission
2. What I have to offer the Commission via this Submission

3. Summary

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Section Two

The Nitty Gritty: The reality of Out of Home (Residential) Care


(Resi hereafter)
4. The children in care

5. Instability of care

6. Children from non-typical backgrounds

10

7. Education

10

8. Daily life/sleep patterns

12

9. Pocket money

14

10. Property damage in units

14

11. Smoking

15

12. Case studies


Case Study One: The Gangster

15

Case Study Two: The Plastic Bag Child

16

13. State-sanctioned abuse and neglect and the statistics

19

14. Drugs again

21

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

15. Prostitution

22

16. Inconsistency in management, programs and how units are run

22

17. Case Study three: Tinder and the Policeman

23

18. Case study Four: Kristalnacht

24

19. Case study five: The car heist

24

20. Team Leaders/Unit Coordinators

24

21. Police at the units

24

22. Violence and Abuse in Out of Home Care as Institutionalised State


Neglect

26

23. Conclusive remarks

30

24. Recommendations

35

Endnote

49

Appendix A (samples of Residential Care Unit Daily notes)

51

Appendix B (Proposal for Dynamic Healing and Education Centres)

136

Note on Appendix A
Samples of Residential Care Daily Notes.
At the end of the main report are 100 pages of daily notes written by staff members on duty in
various Residential Units. They are a unique resource that provide for a true understanding of
the reality of everyday life in Resi units. They exemplify the conflicts, violence, drug use and
other incidents that happen in Resi care every day.
These notes are confidential and are not usually ever seen by anyone outside of the units, the
relevant CSO Manager or certain DHS Staff. However, the Royal Commissioners,
Parliamentarians, policy makers, academics and all members of the general community must be
made aware of what really occurs in Resi State care. Only by knowing the truth may the
powers that be finally act to do what is required and provide the funding and care that is their
legal and moral responsibility.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Personal background:
a/History of my employment in Out of Home (Residential) Care

2009/10: 12 months in Eastern Suburban Melbourne in one unit

2011-13: 18 months in a rural city working in up to six units

April 2014- present: emergency reliever working in Melbourne and rural areas.

I also have past experience in the sector:


1986-88: Casually employed at St Vincents Boys Home (a Christian Brothers facility in
South Melbourne) as an after school carer (4pm-10pm). In this Home, there were about six
separate units each with three or four boys aged eleven-sixteen. I worked in one unit with a
Brother doing the after school home care program: homework, activities, dinner and
bedtime routine.
1988: Reliving House Parent: St Vincent de Paul Temporary Care Unit. I relieved a
House Parent couple each second weekend in a unit with children aged 3-8.
I have also worked voluntarily in Out of Home Care in Germany and Los Angeles.
b/Professional Preface re this submission
Despite my educational qualifications, I have continued to work in Resi care as I have been
building up a new childrens charity (P.E.A.C.E. Inc) that supports child survivors of war
through the creative arts. I have been doing relief secondary teaching and casual Resi work
during this time as this provides time flexibility. For my own social/political reasons, I also
like to work at the coal face in the community sector and to therefore know and understand
personally the realities of the increasing social inequality in Australia and of the development
of a US-style underclass.

2. What I have to offer the Commission via this Submission


I suppose I am the most educated person who has ever worked in Resi care in Australia (and
possibly the world). I dont say this in an egocentric way (!) and I say it slightly tongue-incheek, but also as a matter of observation and reality.
Due to this, I can perhaps offer unique insights to this Commission as well as personal
recommendations about how the massive problems that I describe might be overcome.
Most of all, I intend to tell it as it is without fear or favour. My report is also interspersed
with real quotations from DHS Incident Reports and Daily Notes which, as stated above,
have been de-personalised to ensure no breach of confidentiality.
I can offer insights informed by having worked in Out of Home (Residential) Care facilities in
some of the most disadvantaged and drug-ravaged communities in Victoria as well as in

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Melbourne suburbs. I have worked in units run by many organisations including Vista,
Wesley, the Salvation Army, Glastonbury, McKillop, Berry St and St Lukes (Anglicare). I
have therefore been able to observe how different organisations run Resi units and to
recognise problems that are endemic in Resi care across the spectrum of organisations and
geography.
I am not an academic expert in this area (my Ph.D was related to the history of the civil
conflict in El Salvador in the 1980s) but I am an expert in Resi care at the Coal Face.
Due to my work in initiating and setting up the Alannah and Madeline Foundation (in which I
worked with survivors and families of those killed in the Port Arthur massacre) plus my work
for P.E.A.C.E. (which includes a Healing through Arts project in a Burmese Karen refugee
camp), I have dealt with trauma in other contexts and I am widely read in the area.
In this submission, I express my understanding of the many deep and, in some cases, shocking
problems within Out of Home Care in Victoria. My understanding is that the situation is not
very different in other States as the structures are very similar.
3. Summary
This report will highlight three principal issues that must be addressed urgently:
1. Drug use and the lack of normal routine/sleep patterns in Resi units.
2. An almost zero participation rate in formal education by children in Resi.
3. Instability of placement (children constantly being moved).
I wish to stress an important point that relates to the quality and integrity of this report. This is
the fact that it is generalised. I mostly use the words they and Resi children. However, it is
of course commonsense to appreciate that not all children in every Resi unit face the same
situations as highlighted in the body of this report.
Most observations and commentary in this report relate to the negative. This is what the
Commission needs to learn about. However, of course there are some Resi successes.
Not all children continually take drugs and act violently
and some staff members are excellent and some units
are well run by caring Team Leaders and staff.
However, for the most part, Resi care is almost completely broken from top to bottom. It is
quite dysfunctional. Most children are not properly cared for, their educational development is
not being nurtured and their emotional trauma, grief and anger is not being professionally
managed to anywhere the extent needed. That is, almost no children from my experience are
involved in proper, long-term, planned and managed holistic healing programs. Programs that
some are involved with (personal counselling etc) are piecemeal, irregular, the professionals
come and go and mostly the children just stop attending.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

I submit that Out of Home (Residential) care operates as institutionalised Statesanctioned abuse & neglect for thousands of vulnerable, traumatised young people.
Finally, I make a series of recommendations as to how the most serious problems outlined in
the body of this report can be overcome.
Please note that I have put this report together in just a couple of days. I apologise for any
failings in its organisational structure or for grammatical errors.
_________________________

Section Two
The Nitty Gritty: The reality of Out of Home Residential Care
4. The Children in Care
Children in Out of Home (Resi) Care come from various backgrounds. However, essentially
they are traumatised and behaviourally-challenging young people who have been removed from
their families by the State due to dysfunction, abuse and neglect. They endure trauma-derived
anguish caused by cruelty such as incest by parents and older siblings, being locked up and not
fed for days, physical abuse including being thrown through glass doors, rape with implements,
alcohol foetal syndrome and of course witnessing violence by parent against parent or other
intra-family violence over many years.
The children who are placed in Resi care are children who have usually been placed in various
kinship care or foster-care placements which have broken down due to the behaviour of the
young person and the inability of the carer to manage or handle their abusive and challenging
behaviours.
The children have a myriad of emotional and psychological conditions and illnesses. Essentially,
almost all have PTSD or other diagnosed or undiagnosed serious emotional/mental illnesses such
as being sociopaths or having quite developed sociopathic-type personalities, bi-polar spectrum
conditions and so on. Their souls and minds have been deeply damaged by the severe trauma
they have experienced and they dont understand why life has dealt them the hand that it has.
Most have a huge chip on their shoulder and see all of society as the enemy: police, schools,
DHS, Resi workers, Case Managers and so on. They blame all of these as part of the reason they
have been removed from their families and that their lives have been fucked up(to use their
words). The most central manifestation of their anger and grief is a feeling of powerlessness and
lack of trust.
A disheartening aspect of how many deal with this in everyday unit life is via self- or communal
sabotage.
They have been used to chaos as long as they can remember. Chaos for them is in fact normal.
People getting along peacefully and things running smoothly is abnormal for them. So, if things
are going along well in a unit and especially if a positive relationship has developed or is

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

developing between a young person and a carer, then most (not all) young people will start to
sabotage the quiet, the calm and any positive relationships after two or three days. This is
essentially because they are afraid of getting close to, or trusting, someone else. Throughout their
lives, the people closest to them who they should have been able to trust, abused them and/or
neglected them, abandoned them or caused them terror, fear, grief and inherent sadness. Why
would they want to trust a Resi worker who is likely to disappear soon (moved to another unit,
quit the job, finish studies, get married)? So they cause the calm situation to break down by
suddenly turning on the worker, telling lies about them to other children or to other workers and
so on. Chaos, disorder and conflict is what they are used to and it can actually make them feel
comfortable and in some sort of control. This is the complex psychological and emotional trauma
we are dealing with.
5. Instability of Care
In some cases, young people in care have been moved in and out of up to twenty or more
placements. I recently worked with a child who had been in seventeen placements in two years.
Sometimes they are moved within and between regions/cities. Something typical might be:
A twelve year-old boy (well call him Michael) is moved out of the family home where
he lives with a single Mother. Mother takes weed, occasionally ice, child is unsafe, missing
school, has been arrested for shoplifting and assault.
He is moved to an Auntys house. This breaks down after two months.
He is moved to the Grandparents. This breaks down after three weeks.
Michael is then moved to the Fathers house. Despite being recently released from jail,
the Father is deemed acceptable to have the child as his crimes were not violent or sexual in
nature. However, this situation breaks down after just five days. The child is then moved to his
first Resi unit (which is an emergency/temporary placement) and he is there for five days then
moved to another permanent Resi unit.
Due to conflict with other children, Michael is moved after two months to another Resi
unit with three children. In this unit, a co-resident alleges that sexual abuse/threats have been
carried out by the third Resi child in the unit. That child is kept there for certain
logistical/practical reasons, so the other two children (including Michael) must be moved out.
So he is moved to another Resi unit. But this unit is closed by DHS after six months.
So he is again moved to another unit.
This a very realistic and very common example. This young ten-year-old boy would have been
in seven kinship or Resi placements in around eight months. If he is lucky, he might be in the
next unit for twelve-eighteen months... but could be moved again due to the unit being refurbished, closed down or due to conflict with other children. In some cases, kinship care may be
tried again (eg back with the Aunty) but this again breaks down and so back to another Resi
unit and so on it goes School? Not likely!

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

The children in Resi are removed from their families due to neglect/abuse/fear/violence and
generalised chaos in their lives. However, instead of State care meaning the opposite of this,
often the fear, chaos and violence remain: the Fear of other children and the Violence of being
bullied and assaulted/bashed, the Chaos of moving many times and dozens of staff/carers coming
and going from their lives each week and professionals (case workers, drug workers, CASA
workers and so on) also coming and going from their lives.
6. Children from non-typical backgrounds:
Some children are placed into Resi units as a short-term solution and are not from the same
dysfunctional background as most of the children. This can be where say as single parent is
incapacitated and there is no kinship or foster care available. For these children, they can be
severely damaged and traumatised by being placed in Resi even for a short period.
Essentially, most Resi units are like mini jails. Different people who have no connection with
each other and who have severe problems and (in most cases) who have also committed crimes
and who are violent and in some cases sociopaths, are put together with two-three others who
have the same issues to some degree or other. Placing a person who is not of this background
into this situation is placing them at great risk due to them being exposed to the hardcore
children who threaten, bully, bash or coerce the newbie to take drugs or participate in sexual
activity/exploitation or violence against other children or staff.
The fact that a regular child is ever placed in a Resi unit for even one day is absurd and is an
example of the dysfunction of the management processes in DHS and the CSOs. It is deliberately
placing children in danger of abuse. This is what they are meant to be protected against in State
care. (More about this is in recommendations).
7. Education
An absurd and depressing fact is that only a tiny percentage of Resi children are enrolled in any
meaningful educational programslet alone actual school.
If ordinary parents were known to not be sending their children to school, they would face
sanction or investigation by (ironically) DHS. But when the State/DHS/Community Service
Organisation as Parent does not send the child under their legal guardianship to schoolwell, it
passes under the radar.1
I state completely sincerely that in the past five years with at least 100 different children I have
worked with in approximately twenty-five different Resi units, there would not have been more
than seven or eight who were properly participating in formal education.
This is not an exaggeration. Almost no children in Resi care attend school! This is a bizarre
reality. So, not only are they damaged and traumatised by the abuse they suffered at home
(sometimes from before birth), but, we are ensuring that their plight will be inter-generational
1

I can only state this categorically in terms of Victoria, I have not worked in other States, but I imagine the situation
would not be very different.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

because we (the State as Parent) are ensuring that they leave care barely semi-literate and/or with
no generalist, formal education.
This is due to various reasons:
1. Due to their backgrounds of growing up in dysfunctional or impoverished/abusive
situations or in semi-itinerant families, most Resi children have never been properly
engaged in the education system in the first place. If they had been to school in some
primary years, other children (even at a young age), pick-up on their situation (and
misbehaviour in class) and so they are immediately seen as other, different and are
ostracized, bullied or left out. This, in turn, leads to increasing behavioural issues as
they lash out, rebel or seek attention and they are suspended, expelled or just stop
attending. This becomes part of their normal everyday dysfunctional micro-world of
chaos and underclass. So, by the time they get into Resi, school is part of the enemy
and of course it is almost impossible to start them on a normal routine: off to
school at 8:15am with a nice cut lunch, a wave goodbye and happy smiles They
have never known this.
2. Those who are enrolled in school cant be made to attend by the Resi carers. They
cant be made to get out of bed. Resi carers in the unit have no power to do anything
except to cook, clean, drive and write the daily notes. They cannot make the children
do anything. The children may be woken up and told it is time to get ready for school
but they can simply shout out Im not fuckin going to school, get out of my room ya
fuckin mole/fat cunt/black fuck/bald faggot. This type of language is very common
in Resi units. The carer can attempt various ways and means to get the child off, but if
they refuse, that is it.
Many of the youngest cohort do attend some schooling, but I would say that of the 14/15/16
year-old cohort, not more than 5% would be receiving any meaningful or formal education.
From the notes:
On the way back to the unit, Grace told the writer that she didnt have a very
good day at school. She said that she had been bullied at school and the
principal wouldnt help her, saying that she was no longer at primary school
and thats the way it goes in high school...
...The writer took Grace to school. On the way, Grace explained that she may
be in trouble today for hitting a girl [yesterday] and possibly giving her a blood
nose. Grace said that the girl, who is in her class, called her a Black Dog
which caused Grace to react by hitting her. Grace explained that the principal
told her that retaliation was not a good response and she should not have hit
her. Grace expressed that hitting this girl was not right but said that how was
I not meant to retaliate to someone calling me a Black Dog?
... Grace called for a pick up from school at 11:00am. She complained about
racial abuse at the school and also being picked on for being a Resi kid. She
said words similar to: Theyre fuckin racist cunts and You cant be a Resi
kid and go to that school!

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Some are enrolled in special programs within regular schools (eg going twice a week for one
hour at time) or in other alternative educational facilities. But, my experience of taking children
to these (plus my insights as a trained teacher) is that most of these are superficial and achieve
almost nothing for the child.
For example, a program I know of in a rural town run by a CSO is staffed by regular teachers. It
is called tutoring. The Resi children who dont go to school (almost 100% in this town at the
time I worked there) are offered this tutoring program for up to around three sessions per week
(two hour sessions from memory). The children sit with the teacher/tutor and do some vaguely
educational activities/puzzles and similar. A few children attend because they actually enjoy
receiving some education, others occasionally go because theyll see other Resi children and are
able to get some smokes or disappear with those children after the carer has dropped them off (a
free ride into town). However, those enrolled mostly do not go. They just tell the carer to fuck
off or similar when the carer dares to knock on their door to tell them they have tutoring in an
hour. OR, the child may know they have to go or they will not be allowed to do a certain
activity or get their pocket money. So, they go. That is, they get driven there and stay for a bit
and are therefore put down has having attended by the unit and probably also by the school (it is
probably in the CSOs/schools interest [due to funding], to also have it recorded that the child
attended). However, after say 10-15 mins, the child starts to behave disruptively or abuse the
teachers, so the teachers say if you dont want to be here and are being abusive, please leave.
Back in the unit, it is of course written in the notes and in the diary that the child got up and
attended his tutoring/school program. This would then be reflected in any statistics produced
about school attendance.
To reiterate this most important issue: Almost no Resi children from fourteen-seventeen are
receiving any formal education, are enrolled in school or attend school even if enrolled.
Probably only around 10-15% (if that) of ten-thirteen year-olds are formally enrolled in school
(being enrolled doesnt mean they attend).
This brings me to another major and serious issue about how most Resi children are not learning
or being mentored about how to be active and worthwhile citizens in society with the possibility
of living a more normal, regular life as productive, employed, respected, participating members
of society. This concerns their daily routines and sleep patterns.
8. Daily life routines and sleep patterns
Most Resi children from around thirteen years-of-age onwards (certainly almost 100% at ages
15-18) take drugs very regularly - weed, ice, glue sniffing, chroming or other drugs.
Home-made bongs will often be found in their rooms and while most dont smoke in the units
(many do), most children smoke weed around two-three times per week. (Again, I am speaking
from my personal experience all over Victoria with dozens of children over a five year period).

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

They get their drugs in many ways. For example:

From parents/older siblings during access visits

Shared with other Resi children as a favour, payback or for sexual favours

From regular drug dealers who most of these children know.

This situation of drug taking is horrible and crazy. Again, the Resi carers cant do anything about
it. Incident reports are made and bongs are confiscatedbut the same thing happens the next
day.
From the Notes:

Writer got a call from Shaun at the Detox facility wanting to come back to the unit.
Writer advised him to try to stay there and he can call the unit any time for a talk.
Shaun said he did not want to do that but instead he wanted to come back to the
unit and smoke bongs...

As most children are not attending regular school and take a lot of drugs and/or alcohol they
have completely unstable and unhealthy sleep patterns. Almost all Resi children over
fourteen years-old will be up until midnight or later and then sleep in until 11am or midday.
They have no regular routines and thus are not learning about normal behaviour or how to
survive in the real world. Most will never be able to hold a regular job. From say thirteeneighteen years old (when they leave Resi), they have never had any normal routines of study,
work or sleep. Many will also be brain-damaged due to constant drug use from a young age.
Most also have decrepit or severely diminished respiratory systems due to having smoked
cigarettes since the age of ten or eleven.
In many conversations with co-workers, one often hears the sad repetition of the stereotyped
observation about Resi children: By the time hes 21 hell either be dead or in prison.
From the Notes:

Cailtin called the unit at 2:11am asking to be picked up from in town.


Cailtin told the writer to hurry as she was cold and wet. On the way out
the writer grabbed two towels. As the writer was driving into town, I saw
co-client Sue outside the public toilets. The writer drove into the
carpark and parked outside the toilets. [Caitlin got out of the car]. Sue
was no longer outside and a short while later both Cailtin and Sue
exited from the mens toilets. Cailtin took one of the towels from the
front seat and took it back to the mens toilet and the writer could hear
her talking to some unknown males (sounded like more than one).
Cailtin asked if she could cook something [upon return to the unit] and
the writer told her that the oven and stove are turned off and will not be
turned back on at such a late time.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

9. Pocket Money
Children in Resi receive pocket money - up to $34 per week depending on the agency. This is
also crazy and should be stopped. Some younger children must spend their pocket money with
carers, but most over fourteen years-old, receive this as cash, so the pocket money mostly just
goes on drugs, cigarettes, alcohol or other criminal or socially-negative purposes. The small
number of older children who are on Youth Allowance (if they are enrolled in say a TAFE
course), go hooray when they get paid - as each payday turns into a drug binge and they are
usually in a happy mood so they share it around with their fellow Resi children.
For Resi children, all their needs are met by the agency/State and of course some receive money
or gifts from family members. It is absurd that a fourteen-year-old child can receive $34 per
week to just spend on drugs, Red Bull or Mother high energy drinks, cigarettes and so on. If
they are to receive pocket money, this should be in the form of a State Trust Account that they
have access to at say 21 years-of-age (when hopefully they may have matured a bit and might
spend it appropriately). At the very least, they should not receive this as cash; rather, it must be
spent with a carer and can only be spent on acceptable personal items. Why does a fourteen-yearold child living in Resi need $34 per week spare cash?! Very few regular children would get this
much pocket money.
The theory behind them receiving pocket money is of course logical. It is treating them as a
normal sort of child and allowing them some independence and power over their own lives. It
is respecting their human rights. It is nice and luvy duvy and fuzzy wuzzy and is meant to
leave us with a warm inner glow about how we are so good to these poor, traumatised kids.
This is OK in theory, but when the practice is that most of this money for the majority of
children is simply spent on drugs and alcohol or worse (buying sexual favours or other
exploitative/criminal behaviours), then what is the point? We are simply treating ourselves
as fools while providing drug money to children!
10. Property Damage in Units.
Currently, there is a huge amount of property damage carried out in Resi units. Holes are made
in walls, windows are smashed, staff property damaged, unit cars damaged, microwaves thrown
through windows, fridges tipped over and so on. This is usually due to having multiple children
in the units.
For example, if one child is starting to escalate about something and both staff are trying to
handle the situation and calm the child down, you will suddenly have one or more other children
running up, egging on the other child, throwing something at a staff member or trying to make
the situation worse in any way they can. It is all part of what they consider the fun of seeing
staff stressed or lose control or of their peer getting away with the bad behaviour by the staff
having to leave and go into the office to disengage. In other words the child has won. The
staff retreat and then the children have the run of the house with the staff holed up in the
office for perhaps 45 minutes. The child may have grabbed the phone off the staff member, a pile
of Miki cards the staff member had just bought or similar. If they feel like having more fun

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

while the staff are in the office for their own protection, they might decide to smash some plates
or throw some eggs around.
From a DHS Incident Report:

Jason went into the unit and threw the Christmas tree and other items
around the unit. Jason smashed glass against the unit wall and threw a
two litre bottle of milk on the floor. When asked why he was behaving
this way he said because he felt like it. Jason continued to escalate and
smashed several items of property in the unit. Jason threw a glass at the
office door and it shattered immediately. Staff decided to disengage and
stay in the office at this stage as he was clearly agitated and it was not
safe to be out on the floor. Jason tipped over the entire refrigerator
making a huge mess with yoghurt and other food that was in the fridge.
Jason also smashed a number of smaller items, namely crockery. Staff
contacted 000 and police attended. Jason had already left the unit when
they arrived and staff did not see where he went, as staff were bailed up
in the office as he went on his rampage. The police took a number of
photos of the damage and asked if it was policy to have him charged.
Staff explained that he needed to be charged. Once the police left staff
contacted on-call and then proceeded to clean up the mess and
damaged items. The floor was very slippery and Jenny slipped in some
yoghurt and fell onto one arm trying to break her fall. It was very painful.

11. Smoking.
Around 99% of Resi children smoke cigarettes and I would estimate that around 60% of Resi
staff also smoke (way above the adult average of about 16%).
There is one horrible and completely sickening habit that especially the younger children have.
This relates to bumpers. Bumpers are pre-smoked, thrown away cigarette butts with some
unsmoked cigarette still attached that the children scavenge from bins, street ashtrays or from the
gutter. This is horrible to see, extraordinarily unhealthy and could lead to a child contracting a
serious illness. It would actually be better if these children were provided say four clean
cigarettes per day instead of smoking filthy, second-hand cigarette butts from the gutter! Under
our care, these children are behaving like decrepit street- urchins in Dickensian England. This
habit of collecting and using bumpers is revolting, filthy and of immediate danger to their
health.
Thus, as well having so many other mental and physical health problems, most Resi children
over twelve years-of-age, smoke, and are therefore also destroying their lungs and respiratory
system during their developing years.
12. Case studies One and Two
Case One: The Gangster
There is a twelve-year-old child who I have worked with recently who does not attend any
schooling. His breakfast is going for a bike-ride at around 9/10am (whenever he decides to get
up) to collect his first butts for the day, which he smokes out the back of the unit. Plus, he would

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

almost certainly be diagnosed as a sociopath if assessed and, just like a little gangster, he carries
around a realistic looking gun tucked into the back of his pants when he goes out. He is only
small but walks with his arms slightly curved out like a little macho man.
He states directly that he hates women and has assaulted female staff. Yet, he is allowed to play
the violent, misogynist game Grand Theft Auto. This is despite it being M15+ (the newest
version is R-rated). He should not be allowed to play this, but staff let him, as it would bring
conflict if he was told he wasnt allowed to watch it even though it is illegal for him to be
doing so and terrible for his emotional state. This boy is one of the mostly deeply-damaged
children I have worked with, yet his care is third-world standard.
Sometimes the little child inside comes out and he sings a song and does a bit of a dance. You
realise that deep down, he just wants to be a normal 10-year-old and yet his life is complete
chaos. It is absurd and essentially criminally-negligent that the State as Parent via the CSO are
not doing anything meaningful to heal his trauma, change his life around and give him a chance
to grow into a normal young adult. I would say there is an 80% chance that he will be dead by
the time hes nineteen or twenty or at least in jail for murder or some similar violent crime. He is
only twelve. Surely it is not too late to help this child? However, the CSO and DHS are unable
to provide integral healing programs for this little boy or ensure he lives in a nurturing, caring,
creative, clean, non-violent, non-chaotic environment. Many of these children need what is
unfashionably called tough love.
This twelve year-old boy needs to be told when he must go to bed, that he is not allowed to play
violent video games, must attend an appropriately-designed education program everyday, must
be helped to stop smoking and must not be allowed to walk around with his pistol tucked into the
back of his pants. In fact, he has the only key to a small back shed in which he stores his
guns five realistic looking toy guns. Ones like a pump action, ones like an M-16 and so on.
That is, he has his own private gun cache. He is 12 years-old for Gods sake! Yes, he has severe
trauma and is from a dysfunctional background, but, if we cant help and turn around a small
twelve-year-old child, who can we help?
He needs boundaries and to have order in his life. At the moment, he rules the roost and he
more or less does what he wants and gets away with terrible behaviour. He seeks to have control
over everything and tells the staff what they are allowed to do, when they can do it and so on. To
use an excuse that it would be an abuse of his human-rights to not allow him to do whatever he
wants and to take away the violent illegal game or to carry around a gun like a junior
thug/gangster is an example of how things have moved too far in one direction. This is all about
rights but nothing about responsibilities or provision of care, love and protection via the
imposition of sensible boundaries and proper adult control including saying no or taking things
away (such as the guns and violent game).
Of course this exercise of reasonable control can be done in a modern way which would include
sitting down with the young boy and explaining clearly what is being done and why and letting
him give his opinions. If he starts to rant and rave, swear, abuse and threaten (which he would),

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

the carer would simply say Thats how it is Joshua [not his real name], we can talk about it
again when youre prepared to do so in a quiet, respectful way.
Josh is an example of one child in State care who is only twelve but who is: a/ not going to
school, b/smokes filthy butts he picks up from the gutter and bins, c/ is allowed to play
inappropriate violent games that are demeaning to women, has no normal life-routines and
receives no meaningful, integral, holistic emotional healing or psycho-social intervention and is
not in any schooling. The kids in the Syrian refugee camps are probably receiving better care
than this child.
Let me continue a bit more about this child.
His unit (in a small, rural town) was temporary, but he had already been there for three months
when this writer last worked there. For around two months, the grass had not been mowed (it
was about three feet high and a snake hazard) and there were no chairs or lounge-suite in the
lounge-room - only two dirty bean-bags.
This unit looked worse than the most horrible fibro-cement Housing-Commission house in
Broadmeadows in the 1970s. If neighbours looked over and saw the grass and noticed that the
small child who lives there was not going to school and they often heard shouting plus noticed
him smoking, they probably would have called DHS to report a child being abused or neglected.
He is being neglected. Neglected by DHS/the CSO, the State Government/The Minister and all
of us (the educated adults who run society).
So where was the money the Agency had for this child/unit? Well, it wasnt being spent to
provide:

a clean, safe place for the child or the staff or


to ensure he was receiving any education or
for adequate, meaningful healing programs or
to help him stop smoking.

Case Two: The plastic bag child


I once picked up a new child from a DHS office to take him to his first night in Resi. He was
only eleven. He had been hanging out at the DHS office for about two days while they sorted out
his placement. He had been sleeping in a local motel with a DHS staff member. That is, he had
been in the direct care of DHS for at least two days.
So, I arrived to pick him up. There, in the nice DHS office amongst the case managers, social
workers and so on, was this little child ready to go with me. He had all his possessions in four or
five grey plastic shopping bags. How atrocious!
He was in a DHS office with care professionals including managers. Did not one person
consider using some petty cash or even their own money to buy this poor little child a $15 travel
bag/suit case from the $2 shop? And these were well-educated, middle-class social workers,
child psychologists and middle-level managers of DHS! This was appalling and Ill never forget

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

the look on his face when I arrived and I saw him pick up all his possessions in those plastic
bags. Before he even started in State care, he had been treated like shit by DHS staff. He had
been with DHS for two days. A bit of basic human kindness and consideration would have been
appropriate of DHS professionals. Buying him a nice little $15 case for all his worldly
possessions would not have been too much to expect. Its probable that they didnt even ensure
he had a toothbrush or some new undies or socks in his beautiful, magnificent grey Coles plastic
bags.
Then, the poor little child asked in the car: Are there some other boys in the house?. Yes, I
replied. Great! so I can have some new friends! he said excitedly.
However, he was being placed in a completely inappropriate Resi unit with older boys who were
hardcore including a very violent sociopath who had a charge sheet as long as your arm. I knew
it was going to be bad. Sure enough, the next day he had been bashed by one of the other boys
and had to be moved. And so began this little childs life in Resi no stability and subject to
violence and abuse.
At the next unit where he was placed (where I was also working), the children werent as violent
but all took drugs. This new boy had not been exposed to drugs before in his life. Sure enough,
the first plan of the other boys was of course to get the newbie stoned at the first opportunity.
Around three evenings later (I was on shift), the newbie and one of the others arrived back at the
unit at around 11 pm stoned on Marijuana. This was about two years ago in a drug-ravaged rural
community. If this was the present time, the marijuana would probably be replaced by ice.
This poor little child was excited about Resi.
These children are not dumb. They are street smart.
Deep down he probably understood that due to whatever had happened at home, it was not safe
and so the government had removed him. However, he had no idea about Resi care and
presumably thought (logically) that he was being moved to be put in a safe, fun, clean
environment away from the neglect/abuse/alcoholism. But within a few days in care, he had
been bashed and had started using drugs This is crazy! The local DHS and the CSO knowingly
and recklessly placed this child in danger which resulted in him being physically assaulted and
starting to take drugs - within just a week of being in State protection.
He may have been removed from one negative aspect of his life, but was placed into a situation
in some ways much worse. Over the next few months, he was moved three-four times, had
started smoking cigarettes, was taking weed at least once per-week and had already been bashed
up and was being continually bullied/cajoled into bad behaviours by other children. He was on a
downward spiral due to the dysfunction, mismanagement and basic lack of real care or
meaningful emotional healing programs available for these children. Seeing a 25-year-old
graduate case worker once a fortnight or similar, is not a holistic, integral trauma-healing
program. These childrens trauma is deep and massive. They need a permanent, individualised
trauma-healing and emotional care plan that is serious and involves activities, sessions,

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

counselling, play, art, music and other appropriate therapies and interventions three-four times
per week.
If we can spend $20 billion on submarines and $30 billion of fighter jets, then surely we can
spend as much as we need on our traumatised children. If the PM can justify spending $20,000
on a VIP flight to attend the birthday function of a major Liberal Party donor or a backbench
State Labor MP can spend $50,000 of tax-payers money to study Public Libraries in Paris, then
lets place true value on these childrens lives and futures.
Their value is greater than submarines, rail tracks, roads, birthday parties or study trips to Paris.
In fact, there is no value that can be placed on healing their trauma and providing them a safe,
caring, nurturing environment free of violence, drugs, bullying and chaos.
Jewellery, gold, 1000 year-old historical artefacts and famous works of art are often labelled as
priceless. Well, not really. They are nice material items. Our children (all our children) from all
backgrounds are the only entities in our lives and our society that are truly priceless.
The State of Victoria can spend $60 million to subsidise four days of Grand Prix car-racing, yet a
12-year-old boy in Resi care is placed in a old dirty house with a bean-bag in the place of a
lounge suite and three-foot high un-mown grass. Another child is sent away from a DHS office
with all his possessions in Coles plastic bags. This indicates that the Grand Prix is seen as
priceless for our economy and tourism while these children are treated as a worthless nuisance.
We must provide proper funding for the most disadvantaged and traumatised children under our
care and start to treat them as priceless, which, I imagine is how most of the middle-class DHS
Managers and State MPs treat their own children. Resi children are our collective children.
Let the federal and State Governments get together via COAG and fund care for these children
that provides what is required to stop the cycle of dysfunction, drug addiction, violence,
impoverishment and illiteracy.
13. State-sanctioned abuse and neglect and the Statistics
Recently, I worked in a unit where two of the children (teenage boys) wet their beds, and in
another, where a fifteen-year-old boy defecates in his pants. They are not receiving any
counselling/trauma-healing programs related to these physiological manifestations of their
emotional pain. Instead, our care is that they are not going to school, allowed to go to bed at any
time, sleep in till 12 or 2 pm and are smoking weed or taking ice three-four times per week!
This is not care, it is State-sanctioned neglect.
These children deserve more than being treated as third-class citizens with the State as Parent
(especially the Minister) not really knowing what goes on, because the higher up the chain of
command, the more the figures are fudged, the more glossy reports with boxes ticked make it
appear that improvements are being made as demanded by the last Ministerial or Departmental
review.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

If this Commission (or the Minster) asked the Department or a CSO to provide a report about
Resi children in education under their care, I almost guarantee that you would be provided with a
nice list of stats and a written report showing that 80% of children in their care are attending
school or educational programs. The reality is that they would count the children who are in
deemed enrolment in the local school but rarely attend and children who attend tutoring for
one session each two weeks and similar non-meaningful educational attendance. Please note that
I am not saying that the educational programs are meaningless; rather, that in practice, they are
meaningless in terms of any actual education being provided to the Resi child... because they
mostly never attend or satisfactory attendance is four hours per week.
I challenge the Commission to do some real, ad-hoc investigation about life in Resi. Ask the
Govt (if you need to) for special permission to send a team of investigators unannounced to say
10 (or100) Resi units. They show their ID, explain who they are and say please show us the
daily notes for the past two weeks in terms of what children in the unit are attending or have
attended any formal schooling. Two more pertinent questions would be: how many times have
the police been called in the past two months and what time has each child gone to bed and got
up in the morning each weekday for the past month or stayed in the unit at night. All of this info
is in the daily notes on the computer for each child or written in a DHS-produced desk pad
(different agencies do their note-taking in different ways). In fact, you could probably simply
subpoena the previous months daily notes from say 100 units for a given month and do this
research yourself. These notes are legal documents and are specifically there to be used in case
of legal issues or as evidence in court.
Unfortunately, you could not trust the CSOs or the Department to provide truly honest figures
about anything. They would be fudged, refined and massaged.
From a DHS Incident Report:

Alex and Paul did not return to placement. Writer rang Alex at 10pm and
Alex said that he was on his way to Melbourne. Writer asked him to
prove this and he gave his phone to the train conductor who confirmed
this. He said that the train was almost in Melbourne. Writer could hear
Paul in the background and Alex said that EF and GH (from another unit)
were with him also. Writer rang Alex once again at 11.10pm and he said
they were walking around Melbourne but would not tell writer where
exactly where.
From the Notes:

At around 11:00am, Roger banged on co-client (Shauns) door and


Shaun got up not too long after looking half asleep. At around 11:30,
Roger suddenly escalated relating to Shaun, saying that Shaun had
given him lip and that is why he was getting angry Roger made
physical threats toward Shaun who had gone into his room and took two
kitchen knives and attempted to break in to Shauns room witnessed by
Fred (worker). He also kicked Shauns bedroom door very hard about
fifteen times. He then went around and was banging on Shauns window.
Roger went to Shauns door once more, he kicked it again and the door
opened and he got inside Shauns room. When Roger entered Shauns
room Peter (worker) entered the room for fear for Shauns safety. Roger
was standing over Shaun with clenched fists while Shaun lay in a
defensive position on his bed. Shaun appeared to be upset and afraid of

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

being assaulted. Roger was yelling abuse at Shaun and appeared angry
and severely out of control. Peter stepped in between the two boys and
stopped an attack from Roger against Shaun
After police left, Shaun went for a drive with Simon. Shaun was in a
calm mood and in a pretty good space but had indicated quite clearly to
the police and staff that he doesnt feel safe here and that he wants to
leave or for Roger to have to leave.

14. Drugs again: One Resi unit in Bendigo was right next door to a known drug dealers house.
The CSO knew and I presume that someone in the DHS office knew and of course the police
knew. The Resi children (including a fourteen-year-old Intellectually-Disabled child) was
visiting this sleazy guy and getting weed. Nothing was done. Again... if this was a regular family
and it came to DHSs attention that the parents were letting their fourteen-year-old intellectuallydisabled boy hang out with drug dealers and use marijuana, there would be an investigation and
he would possibly removed from them to be put into State protection.
Later on, the unit had been changed to a girls-only unit. One day, one of the girls who was
sixteen years old, announced that she had a new boyfriend - a 32 year-old guy she had met next
door when hanging out with the drug dealer.
I have worked in another unit in a different rural city which also is in front of a known drug
dealers house. Again, the Resi children go there and are often seen sitting on the porch, smoking
and talking to the house residents/drug dealers. How do we know they are dealers? Well,
different cars come and go from around 10pm till 2 am and stay for around two minutes each in
the driveway, while someone comes out to the car window. The car then drives off. I personally
reported this apparent drug den to the police and explained that it was opposite a Resi unit. I
guarantee no action has been taken. I didnt bother speaking to someone from the CSO. They
already know. Even if they didnt know, such information would be deemed a nuisance and
irrelevant. Their answer would be what can we do about it?
From the Notes:

Writer arrived on shift at 6.30pm and Tash appeared to be in a really good


mood. She put on a movie and writer and Jane sat watching it with her.
Half way through the movie, Tash received a phone call from a boy called
Carlos and was chatting to him until he asked her about injecting drugs
and she replied that she had to move to a private area as workers were
listening. Tash returned to the lounge stating that her new years wish had
come true and that she was getting stoned tonight. Writer talked to Tash
about staying safe and away from injecting drugs.
From the Notes:

Daniel and Lachie came into the kitchen so Lachie could make his noodles
and on the way down they were flicking a lighter near my hair, back and
face and also near Angie. Lachie did it first then Daniel grabbed the lighter
and he tried to do it to me, getting very close to my head. I told them that if
they connected the lighter with me or Ange they would be charged with
assault.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

It was only when I took a defensive stand and they saw how serious I was
they both backed off. Lachie was very boisterous, loud and swearing in the
kitchen then he started trying to put his feet in Daniels face. Lachie then
said to Daniel watch this and tried to rub his socks in my face. I told
Lachie to get out of my space and step back. He tried to do it a few times,
quite forcefully and I told him if he did it again I would have him charged
with assault. Daniel got up and went into his room and Lachie followed him
a few minutes later.
Lachies favourite saying since he came home today has been suck a
dick and suck a cock grandma. A short time later both boys were in
Lachies room and when I called out Daniel opened the door standing
behind it pretending not to be there. The room was full of smoke, but it
was not tobacco. It appeared to be marijuana, I asked Ange to come up to
the room and she confirmed this. I rang the Police to inform that Lachie
had returned to the unit after absconding as they had requested. They
came and spoke to Lachie and then also noticed the smell. The officer
asked if they had been having a choof tonight mate? Lachie laughed and
said yep, we have.

15. Prostitution
One girl in a unit close to inner-city Melbourne was only sixteen and prostituting herself. She
would go outside, get in some car and come back one-two hours later and repeat this three-four
times per night. She was all dressed up and made up. The staff knew what she was doing, and in
spite of her young age, she was just allowed to continue doing it. It was for drug money as she
was also on ice and a heavy weed user. For this girl, Resi just meant a bed, food and shower
while being a street prostitute and becoming a brain-fried ice addict continually putting her
health and life in danger. It goes without saying that she also was not in any schooling. Again....
if regular parents allowed a sixteen-year-old girl to be taking ice, not attending school and
working as a street prostitute, she would be taken off them and placed into state care! But
she is doing this in State care!
16. Inconsistency in management, programs and how units are run.
The best adjective to describe State Resi care is that it is absolutely and completely inconsistent.
There is no consistency between the various CSOs and even the same CSO in different regions.
Indeed, even how a particular house is run can depend on the individual team leader. Of course
this is fair enough to some extent; there can be some differences. However, when the
inconstancies relate to basic rules, regulations and what children are or are not allowed to do, this
causes problems.
Due to different backgrounds and educational levels, Resi staff members are completely
inconsistent in how they care for the children. Many have very low education.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

17. Case Study three: Tinder and the Policeman


Some staff are well-intentioned but young and act inappropriately. In a unit just two weeks ago,
there was a young female worker around 22 years. She seemed to think it was good to be cool
with the children and more or less act like them. Well, NO, carers are meant to be role models.
I was astounded with some things she said/did with the children. For example, we were in a
computer room where the children had internet access. One girl was on FB and then started to
ask the worker if this person whose photo was on the screen was the police officer the worker
had gone out with.
The carer then explained to me in front of the children the full story (which the young people
already knew). The carer said:
I was on Tinderyou know that App which is basically a date-rape site. I chatted with this
one guy who said he was a policeman and as he said he lived near here, I asked if he had been to
this Resi Unit where I work. He said yep I was there last week when I had to serve a warrant
on Peter. I said fuck! really?.. so I met up with him and we started a relationship. Then I found
out he was a fuckin liar and was married.
Resi girl: yeah so we know who this fuckwit is now, fuckin cunt if he comes over here
again, Im going to say in front of his fuckin cop mate all about how he was going out with a
worker here even though hes married. Hes going to be fuckin embarrassed that fuckin dog!
This conversation continued for a while in the same vain. The whole thing completely
inappropriate for so many reasons: 1/ Carers should not share their private info with Resi
children. 2.Sexually inappropriate language and context. 3/ bringing a police officer who works
in that area into the situation. 4. Too many other breaches of basic ethics and protocol to list
here!
There is basically no training or proper induction for most staff and as pay and conditions are
atrocious plus the potential for being assaulted, falsely accused (which can ruin peoples lives)
and having to work nights, means that it is hard for the agencies to recruit staff. They are
desperate and sometimes take on people who shouldnt really be employed. Sometimes they
employ absolute idiots.
Staff turnover is of course very high due to stress, assaults and bad pay and conditions. Until just
last November, staff with the Vista agency did not even receive penalty rates for weekend work!
I doubt that this was even legal. It certainly wasnt moral. How would they expect a person
giving up a weekend and faced with being physically assaulted and constantly verbally abused
to not receive penalty rates? I can only imagine the type of desperate people who put up their
hand to work for that CSO! How can each CSO have different pay and conditions when all are
working for and on behalf of the same Govt Department, doing the same work and the CSO
receives the same amount of money from DHS for each child they look after? Weird.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

18. Case study Four: Kristalnacht


In one unit where I worked, the other carers told me of what had occurred the previous week.
This was a so called therapeutic unit with three smaller boys (ten/eleven years old). One
evening, one of the boys calmly announced to the staff that at 1:30am he was going to smash all
the windows in the unit. The staff could not do anything. If they called the police, the police
would have asked, has he done anything yet?, If the answer was No, the police would have
said Well, we cant come and do anything if he hasnt broken any windows yet.
So, the staff basically waited until 1:30am, and sure enough, this skinny little child who could be
moved with one finger, started smashing all the windows and so the staff had to retreat into the
office to keep themselves safe. If they had approached the boy, they could have been injured by
flying glass. Of course the police were then called, but it doesnt take long to smash windows.
So, by the time the officers arrived, the young child had smashed almost every window in the
unit with a damage bill of about $12,000. Then, apparently, he did almost the same thing about a
week later!
19. Case study five: The car heist.
In a rural town a few years ago, about three Resi children broke into the office of the CSO in the
town centre and knew where the keys to the outside car park were kept (and the car keys). The
car park contained around ten fleet cars. They stole a car and rolled it a few kls away. Lucky no
one was killed. The CSO was apparently not overly concerned about this, so they didnt change
the locks or move the open box in the inside office where the fleet keys were kept and the same
thing happened about a week later!! I cant remember if a car was smashed this second time.
20. Team Leaders/Unit Coordinators
Team leaders or unit coordinators range from great to hopeless. Unfortunately, too many are
hopeless. As they are slightly higher up the pecking order, theyll do as much as they can to get
away from the unit that is, to be away from the verbal abuse, physical threats and all the usual
problems. This absence is of course often downright unfair and opens up other staff to danger.
For example, there might be just two staff on for a particular period of time with four children.
The team leader is rostered on with say a casual carer. However, the Team Leader will have to
go to the office for a meeting or to do some other important task and thus leave a single staff
member with three or four children. Things like this happen often.
The staff ratios are different even in the same region or town. It makes no sense. For example,
Wesley Southern has just one staff member rostered on during most of the day. And this is with
up to three or four high risk children in particular units. This is absurd and dangerous. Whereas
you may go to a unit run by another agency in the same region and with better-behaved children,
but theyll have two staff rostered on at all times. Nothing makes any sense.
21. Police at the units
One interesting piece of research that would be enlightening would be if the Commission had the
power to subpoena police information (or info from the Resi units) about police attendance.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

There are some units where police are called three times a week. I worked somewhere last week,
and the other person told me that the police were called three times the previous day.
An amazing statistic to find out would be the total number of police attendance to all Resi units
in the whole State. This would be a figure that would shock and horrify but would certainly be
very illustrative of, and support, this reports findings.
In Bendigo, I would say that police attended Resi units an average of two times per week. In fact,
I believe that the figure would be closer to an average of three, but it is best to be academically
conservative in research or formal report writing. With six units in Bendigo at the time, that
would add up to twelve police call outs per week. This would give a figure of approximately 624
police call outs to Resi units in just one town in a year. However, lets halve this figure to be
really academically conservative so no one can accuse me of exaggerating or being
alarmist/extreme in my language or reckless in my methodology. So lets say there were 300
police call-outs in Bendigo and a similar figure for Ballarat, Traralgon/Sale/Churchill and the
Geelong region. This adds up to around 1,200 police call outs for just these towns/regions using
an extraordinarily conservative framework. This doesnt include the hundreds of units in
suburban Melbourne and outskirts and other regional towns. So, all up, including Melbourne,
there must be up to 4-5,000 police call outs to Resi units each year!
Often when police come, the language and behaviour of the young person hardly changes. They
still swear and rant and rave and dont really care. If they are charged for property damage or
even for assaulting a staff member or a police officer, they know that as they are only fourteen or
fifteen (or 12 or 13) years-old, it wont really mean anything. When they finally have to face
court, their lawyer sits down with the police prosecutor with the 80 charge sheets and then this
number is whittled down to about seven or eight of the lesser charges. They basically get away
with most crimes they commit including shop lifting and violent assaults. There are mostly no
consequences for any of their actions both in Resi units and in the community. This is also not
teaching them about how to survive in the real world.
They verbally abuse and shout their heads off to Resi workers and think this is a joke as they
know Resi workers cant do anything about it. They get used to this behaviour and think that
there are no consequences to their abuse, vile language, insults and threats. However, the first
time they speak to someone like that in the real world outside a pub or similar when they are
say seventeen or eighteen-years-old, they will find their head smashed into the pavement. The
people they will be around in the streets will not take their bravado, insults or verbal abuse and
they will quickly be put in their place.
From a DHS Incident Report:

Writer arrived on shift and Mick was lingering around the office and pacing
and Jake was in an agitated state. Mick was making snap remarks at staff
and staff ignored his negative comments. Mick and Jake walked out the front
of the unit and proceeded to throw rocks at the unit window. Fred went out of
the unit to tell them to stop throwing rocks at the window and Jake threw
rocks at Fred to just miss. Not long after, Fred was leaving the unit in the unit
car. But Mick entered the van and would not get out while making threats

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

toward Fred. Staff told Mick that the police would be called if he didnt get out.
Mick still didnt get out and staff then rang the police. Mick eventually got out
but he then stood on the tow bar of the vehicle stopping Fred from leaving.
He eventually got off and then walked towards Fred and spat at him. Mick
then came back inside and made more threats to staff .The police arrived at
the unit and spoke to Mick and Jake however could not charge them for
anything. Mick gloated to staff after the police left that he didnt get into
trouble.
______
From a DHS Incident Report:

At 8.30pm writer received a phone call from a young person by the name of
Susan. Susan stated that she had just received a call from Rick and he had
made several threats to harm her. Susan said that Rick abused her calling
her a fuckin slut and a retard because she went to the special school. She
said that Rick thinks she owes him money and must pay him back or she will
get bashed and stabbed. She also said that Rick threatened to go to her
house and throw rocks through her window. Susan said that she was shaken
by this phone call and she fears for her life and doesnt know what to do as
she has already gone to the police about Rick but they have havent done
anything about it.

When I worked in Bendigo, I often wondered what the regional DHS manager was doing all day.
Did he not read incident reports? If he had, surely he would have investigated why the police
were called 30 or 40 times the previous month to the local Resi units? Maybe he might have
thought that not all was quite right and the situation needed to be investigated? But this would
not be welcome. He would have to come up with solutions or let higher-ups know about the
problems and apparent dysfunction and this would have upset or threatened his nice little, wellpaid position.
I would estimate that the Minister could get rid of around 25% of middle and high level public
servants in the Child Protection/Out of Home care division and it would not make one iota of
difference to the care the children are receiving. The millions saved could be used to employ
hundreds more coal-face child protection officers or suitably educated Resi workers. This would
be a much more effective use of taxpayers money.
22. Violence & Abuse in Out of Home Care as Institutionalised State Neglect.
This Commissions principal objective is to examine sexual abuse. However, despite some
specific cases of abuse by carers in contemporary Out of Home Residential Care, from my
knowledge and personal experience, the situation of abuse in Resi care relates mostly to abuse by
Child against Child.
Sometimes children in care make false allegations against staff. Very rarely to my knowledge
has the alleged abuse actually occurred. If a child dislikes a staff member (who, for example,
may have been responsible for doing a room search and finding a stash of drugs which then led
to police charges) then the child knows they can cause real problems for that staff member if
they want to. Im sure abuse happens currently and the Commission is probably finding out

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

about such cases. However, I would imagine that the total number would be very small
(especially in consideration of the thousands of staff in Resi throughout Australia).
I hope that the Commission is able to fully examine generalised abuse and violence in Out of
Home care (as highlighted in this report) and that the Terms of Reference are not too narrow to
incapacitate the Commissions ability to adequately examine these issues.
If this is the case (or the Commission is only able to deal with non-sexual abuse superficially)
then I submit that the Commission should recommend a separate Royal Commission into
Residential Care be held, as the issues at play are too important if they cannot be properly
investigated and appropriate recommendations made by this Commission about violence and
abuse in Residential Care the majority of which is not sexual.
Child Vs Child abuse happens almost every day in most units to some extent. The second
largest amount of abuse would be children abusing and assaulting staff or damaging staff
property (such as scratching cars, letting down tyres, smashing car windows etc). I know of an
incident when a staff car was burned when a child set the garage on fire.
Most abuse is verbal abuse and frankly, you have to let this go in one ear and out the other.
This is part of the job. BUT, real threats and actual assaults against staff happen every week
somewhere in the State. In the country as a whole, I am sure there would be a Resi staff member
assaulted every single day in some unit somewhere. So, it must be made clear, that despite some
real duds working in Resi, most are sincere in wanting to help the children and I have not the
slightest reason to consider and no personal experience suggests that Resi is full of actual or
potential paedophiles or abusers of children on a mass scale or even on a small scale. I believe it
would be negligible.
In Resi care, when it comes to abuse, it is the adults who are being abused and assaulted en
masse by the Children.
From a DHS Incident Report:

At 8pm Jack asked for a ride to the shops to ride his scooter. The writer
informs Jack that this isnt possible as it was too late and that he would
not be able to scoot at the shops. Jack didnt accept this and began
abusing the writer, stating that he was going to find the writers car and
burn it to the ground and called the writer various names like cock
sucker, paedophile and that the writer rapes little children.
________
From a DHS Incident Report:

Writer (staff member Sandra) was driving back to the unit from
Nunawading with Farouk and Tony when Farouks behaviour took a
dramatic turn. Tony was pulling at the steering wheel and honking the
car horn while the car was in motion and Farouk suddenly pulled the
seatbelt of the writer hard, yanking her backwards away from the
steering wheel and leaving her breathless. Writer pulled the car over and
stated that this was completely unacceptable and unsafe. Writer stated

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

that this was the boys last chance to behave appropriately in the car but
neither boy accepted this and writer felt very unsafe and exited the
vehicle.
The unit was called for staff to come and take the boys in the other car.
While waiting for staff to arrive, Farouk was extremely verbally abusive
towards the writer, detailing all of the ways he was going to get her back
at the unit. Strategic and calculated threats were made about stopping
writer from getting into the unit, waiting for her outside the door, waiting
for her to leave after her shift, threats to wrap Tonys scooter around the
writers head and general threats of bashing writer and getting her fired
from her job.
A call was made to another staff member for help and once staff arrived
Farouk refused to get into the other vehicle saying that he was getting
back into the car with writer. Writer refused to drive in a car with Farouk,
so Farouk slowly pulled off the rubber seal from the passenger front
door. He stared writer straight in the eye as he peeled it off and was still
making threats towards her and being overly verbally abusive. Dog
faced slut and f***ing useless C*** were the most commonly used.
Writer attempted to get into the car to drive away but Farouk came
around to the door and slammed it into the driver first, then opened it
again, then slammed it into the driver once more before opening it and
standing at eye level with writer and still pouring out a continuous stream
of threats and insults. Farouk eventually decided hed had enough and
got into the other vehicle allowing writer to return safely to the unit.

The vast majority of abuse is child against child. This is endemic, continual and institutionalised.
Most such abuse involves bullying, physical assaults, threats, inducement/pressure to commit
crime, inducement/pressure to take drugs/deal drugs and general violence or threats of violence.
There is definitely a reasonable amount of child to child sexual abuse (or attempted sexual
abuse) or child to child sexual contact that may not always be abusive. This is mostly done
behind closed doors or outside of the unit. As to the percentage of all child to child
abuse/exploitation that may be sexual, I cant really provide a reasonable estimation. I would
hazard a guess that the figure maybe around 30%. So this would be hundreds of incidents every
year (of course some more serious than others).
From the notes:

Writer arrived on shift and Farouk started to push Tony around in the
unit when walking past him and making comments like Im going to bash
you. Writer advised Tony to ignore this and perhaps go and watch TV in
his room. He went into his room, however Farouk started banging on his
door and told him to open up or he would bash him. Farouk started
calling Tony his Bitch and Tony replied youre the one who wanted me
to suck your dick last night. Farouk then escalated further, clenching his
fist and becoming aggressive so writer intervened. Farouk then went
and did some colouring and writer congratulated him on doing this.
However another client Jason - stirred the pot even more repeating to
Farouk what Tony had said not long before. Farouk got up and ran at
Tony throwing punches and both clients got into a scuffle with both
clients throwing several punches. Writer intervened and separated the

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

pair and things settled for a bit. Writer then took Tony out of the unit and
took him for a drive. During the drive, Tony disclosed to writer that
Farouk told him to suck his dick while they were alone in Farouks room
last night.

As I said earlier, Resi Units are a bit like a mini jail. Many children have carried out violence in
public, at parties or in the street. Some have assaulted police. The twelve-year-old I mentioned
earlier, went to court a few weeks ago and had around 40 charges including for car stealing and
assaulting a police officer. A sixteen-year-old child I worked with recently was looking over his
charge sheets ready for a meeting with a lawyer. The number of criminal charges he was facing
totalled 120!
Young people in care are abused, bullied and bashed by other Resi children. The worst cases
involve younger children (and newbies) being placed with older, hardcore children such as
described earlier. Bravado, threats, destroying property, severe bullying and of course actual
physical violence and assaults are all part of Resi life each week (in most places).
Some children are often very scared and other times they know the other person will not follow
through with threats. However, this atmosphere means that Resi units are far from the caring,
nurturing and safe environments they should be. Everyone is almost continually on edge and
stressed almost all the time (workers and children) or have a real fear for their personal safety.
Two examples: I walked into a unit one evening. I did not have time to settle in. There was one
poor child of around 12-years-old cowering in the corner of the staff office as he had been
threatened with being bashed by an older child. He remained there for about an hour until the
other child was definitely in his room with the door closed and we could hear the TV. The other
staff then half-ran with the fourteen-year-old to the childs room, saw him safely into bed and
made sure the door was locked from the inside. They told me that it was like that three-four
times per week!
Just two weeks ago, a really lovely boy of around sixteen but with an ID was being bullied by
two other boys. They were putting soapy water outside his door (so he would slip if he came
out), banging on his window and telling him not to come out or they would smash his head in.
The police arrived and it turns out that the boy being bullied had called 000 from his room. He
came out yelling Im sick of this shit, either they go or Im going!.. When he came out of the
room, he was trembling. This child is a gentle person with an ID. He wouldnt hurt a fly. Why is
he in a Resi unit with violent bullies who make his life hell?
Again, this is an example of a young person in State care not being cared for. Indeed it is the
opposite. He is in a situation of continual abuse and fear while in State protection.
This is another example of Institutionalised State neglect and basic abrogation of the States (and
the Ministers) duties as legal guardians of such children whose number one legal responsibility
is presumably to provide a safe, caring, nurturing and rehabilitative environment for these
children. The exact opposite is being provided for probably 60-70% of Resi children. These
children live in a hazardous, noxious and often threatening environment with a system that
appears indifferent to the reality of their situation. This leads to an increase in their existing

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

mental health problems such as general anxiety, separation anxiety, bi-polar spectrum disorders
and sociopathic tendencies.
In terms of legal issues, it would appear on prima facie evidence that Resi kids who have been
victims of such continual and debilitating abuse and bullying in State care plus being influenced
to take drugs and carry out criminal activities and violence, could rightfully sue the State for
causing them clear spiritual and emotional harm, on-going mental anguish, not providing an
education they are legally bound to provide and for all sorts of other physical and emotional
harm that is inflicted upon them every day in State care. Indeed, for many children in Resi, the
word emotional torture would not be too strong a word to describe their daily lives. This, plus
the neglect in terms of their education would surely be a valid target for a massive class action?
Staff are subject to massive bullying and emotional and physical violence, but staff are adults
who choose to work in that field. The children are in these placements without choice.
23. Conclusive remarks
I wish to again emphasise that this report is generalised in its language (for logical reasons) and I
have discussed the situation faced by most Resi units and children in Out of Home Care. Not all
children in all Resi units face the issues discussed in this report every day or every week or live
in a frightening and chaotic environment. The worse thing I could do in presenting this report is
to be overly polemic or extreme in my language as I express my knowledge and indeed, my
anger, about what I know and have seen and heard. In most cases, I have attempted to be
conservative in my evaluations and expressions of my thoughts and feelings.
I dreamed up, initiated and co-founded The Alannah and Madeline Foundation with Walter
Mikac. I am a Member of Rotary International and was a Rotary Delegate to the International
Peace Forum in Hiroshima a few years ago and was the District 9800 leader of and mentor for
four young professionals on a Study exchange to Germany last year. I am a father of two and a
Grandfather of four. I am a moderate and responsible person, not prone to extremist language or
ideologically-inspired polemics. I am writing this report in a frank and direct manner because if
I didnt tell it as it is, I would be joining what is a type of institutional cover-up of this issue
and I would be abrogating my responsibility to the community as a whole including caring and
concerned law-makers who may wish to do something about this terrible situation,
I dont want my beautiful grand-children to grow up in a society where 15-20% of our fellow
citizens are semi-literate, angry, mentally disturbed, dissociative, violent thugs. Lets see about
the man who just allegedly murdered that beautiful seventeen-year-old school girl in Melbourne.
He is only 26. An excerpt from The Age about this case states: The court was told in 2014 that
Price, who was abused as a child, suffered from schizophrenia and psychosis.... Sound
familiar?! I would imagine there is a high chance this alleged murderer was in State care in his
earlier life.
We need to STOP this cycle of dysfunction, violence and of not doing anything to really heal and
rehabilitate such people when they are relatively young. If we dont, we will have thousands of
men (and some women) like this carrying out savage violence in the future to our sisters,
mothers, brothers, fathers, children, grandchildren and grandparents.

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Early intervention and spending whatever amount is needed to provide proper care, reformation
and rehabilitation for these people when they are very young is the key. Trying to heal and
reform when they are sixteen and seventeen years-old is too late.2
Back to the Resi issue
If I was asked to put an estimate on the percentage of units of a particular type, I would state that
not many more than around 5% would be very good with high quality care and very caring,
responsible staff/Coordinators. The next 20% might be adequate but with a very mixed staff or
only a medium level of care and commitment (or ability) shown by the Coordinator. The next
40% would be units that are quite dysfunctional with some very inadequate staff and an apparent
lack of care in a general sense (as seen by how dirty the place is kept) plus with a high-level of
abuse/violence and incidents in the unit on a weekly basis. The final group - around 35% - are
very dysfunctional, with massive and continual dangerous or violent incidents occurring almost
every day, some atrocious staff and some children living in terror. Almost all children in the
three lowest ranked unit types would not be going to any schooling, would be taking drugs
regularly and carrying out acts of violence against other children or staff at least each two-three
days.
Of course, by its very nature, Resi is always quite mixed and can change quite quickly. Great
staff might be in a unit with one or two atrocious children and nothing they do changes anything
much. One Unit might be working well where the staff had started to get a child back into school
or starting a TAFE course but then a new child moves in who is disruptive, bullying and a
2

Indeed, true early intervention really means when they are babies and in some cases still in the womb. We
(society as a whole) through Centrelink, kindergartens, child care centres, primary schools, the police, medical
personnel and so on already know who the inter-generationally dysfunctional and mentally low-functioning families
out there in the community are. We shouldnt only treat this dysfunction as a joke to be made fun of in TV comedy
sketches about bogans. It is not a joke. A truly caring society would use tough love on people in this situation and
design a legally- mandated framework of early intervention that starts when the baby is in the womb. By the time
children from such dysfunction and under-class are in Grade Two or Three, it is essentially too late. Even if we
basically live in a free society, people should not have the freedom to bring their children up into intergenerationally brain-numbed, semi-literate, drug abusing families relying on State welfare to survive and who have
no basic parental skills or knowledge of how to impart love and care upon their children with patience,
understanding and purpose. We dont want everyone out there to be a clone of some Brady Bunch-esque perfect
middle class family! Im not saying this. I am simply expressing that if such people/families are living on State
welfare, then to receive this, the State should be able to mandate the attendance at regular sessions relating to
parenting skills, household budgeting/finance, quit programs, diet and nutrition, drug education, and
literacy/numeracy and similar. Parents could be legally designated as at risk by a specialist, legally-mandated
team made up of say a senior Centrelink officer and other designated officials such as from DHS and the Police. The
mother/partner and any other adults living in the house should have weekly tests for marijuana and other drugs. If
the parent misses a certain number of the educational sessions in row or is found to have taken drugs, they should be
housed (with their children) in specialist healing and rehabilitation centres for a month at a time. This would be
under the Mental Health Act (like mandated State interment of people who have acute mental psychosis). Why?
Because such people have mental health issues that are inter-generational and affect their ability to work, learn, be
healthy and bring up children in safe, clean, drug-free, violent-free environments. We must stop this cycle.

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

control freak or bordering on sociopathic and two weeks later, the unit can be completely
different, turned upside down and all the kids are running amok.
Anyway I trust you understand what I am explaining. I have put forward the above statistics
not as part of an empirically-based, scientific study (which obviously it is not), but as an attempt
to place my report within a rough statistical framework based on a reasonable estimate by a
passionate but also highly educated person (ie the above statistics are based on an educated
guess).
I suppose I am pleading for more answers. Lets really find out! A full, independent enquiry or
Royal Commission into these issues is the only way to do justice to the crucial issues that need to
be examined (if this Commission is unable to due to its Terms of Reference). The lives and
futures of thousands of children are at stake plus the lives of thousands of ordinary citizens in the
community who will be affected by violence or crime committed by these people or the criminal
underworld they are or will become a part of.

Young people in Out of Home Care have been deeply traumatised by sexual violence,
physical beatings, other abuse, neglect, food deprivation, drug use/abuse by parents,
alcoholism, grief & loss, instability and by living in constant fear. Other related
manifestations of dysfunction that many have experienced include things such as living in
squalor and filth, witnessing violence and not attending school.

Not all have suffered all of the above. Most have suffered four-five major abuse
incidents/patterns. It is insane that many of these manifestations of dysfunction and
violence continue or become worse in State so called care.

Young people in Resi are: manipulative, deceitful, inventive, angry, hurt, bitter, hateful
and still very fearful. You cannot trust anything they say. They lie constantly because
they almost have no trust in anyone else and they think they must lie to survive.3

Some show the other natural human emotions at times: kindness, being apologetic,
laughter, fun, creativity etc. It is sad how rare this is.

Resi children are resilient and street smart. Resi children know what has happened to
themselves and although they dont understand why, they can verbalise their own pain
and often do. If they are angry, sometimes theyll shout to a staff member something like
the following (from a real conversation):

You dont know what its like! You dont know what its like to be abused by your
father, while your mothers a fuckin alcoholic! They tried to drown me when I was four and I
was thrown through a glass window!. Fuck! I just wanted to use the phone and you act like its
the end of the world. This is a fuckin shit hole! Youre all fuckin dogs! Fuckin hell ya stupid
cunt, just let me use the phone to call my sister!!

3 Again, I am talking about most, not all children in Resi care.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Staff: Mary.. please stop shouting and we can talk about.


Mary: Just let me use the fuckin phone!!
Staff: Mary, last time you apparently didnt give it back for an hour and it says in the
notes that you were banned from using it for three days except on speaker phone with the staff
member holding it. So if you agree to that, you can call your sister
Mary: (at the top of her voice): Thats fuckin shit shes my fuckin sister..MY
SISTER!! How would you like to not be able to talk to your sister in private!!
Staff: I cant go against what Ive been told, you know that. I can get in trouble
Mary: Fuck! Youre meant to be caring for me, you dont know what I went through
(starting to sob loudly) and now Im not even allowed to see my sister cos her boyfriends a
drug dealer or some shit and you wont even let me talk to her! Youre a fuckin ugly fat cunt, no
wonder youre not married! Oh well, Ill just go out and smash all the plates and chuck all the
food around and youll have to clean it up you fat, ugly mole!

Resi children can be violent, are very verbally abusive almost all the time and due to
feeling powerless and that they have no control over their lives, will seek to gain power
and control in any way they can. This will especially manifest itself in bullying and
manipulating younger, smaller, newer or weaker children and manipulating staff and
trying to play one staff member off against another.

Resi children are constantly abused by other Resi children.

Staff are constantly abused by Resi children. Staff are frequently assaulted by Resi
children.

Most Resi children do not attend or participate in formal education.

Most Resi children over fourteen take drugs up to three times per week.

Most Resi children have no normal life/sleep patterns. Because they dont go to school,
but take drugs and stay up as late as they wish (or play X-box or watch TV in their rooms
until all hours), they sleep in until midday or 1pm. They are not learning anything about
getting along in normal society.

They are being set up to fail and to simply get into a life of crime, jail and early death.

Many Resi girls fall pregnant at 14/15 or have had abortions. Some prostitute themselves
for drugs and cigarettes (boys do this too to a lesser extent).

Resi units are like mini jails.

The running of the units by the various CSOs is completely inconsistent and sometimes
atrocious.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Not all Resi children are abject failures. Not all are violent, abusive, not attending school
and constantly bully or abuse other children and staff or are victims of violence and abuse
in care and without hope for a better future. The vast majority are, but not all. There are
some children who are receiving near to adequate care and who will leave Resi able to
make that next step in their lives and function in the real world and even continue to
study or gain employment.

However, a large percentage of Resi children live as in a mini jail. Many would be better
off in Kerobokan jail in Bali in the programs run by Sukumaran and Chan. Most Resi
children have already started in a life of crime. Resi care does not reduce this, it mostly
enhances this due to mixing new or younger children with other hard-core children
from whom they learn more criminal tricks of the trade, how to abuse staff, to smoke, to
take drugs and so on.

Most Resi children, even at just fourteen or fifteen years-of-age, have up to 60 or even
100 police charges. Many will leave Resi at eighteen with no adequate leaving or postcare plan and will become hard-core drug dealers, stand-over men/women, perpetrators
of violence, bashers, armed robbers, rapists and will end up as drug users living in
squalor in some seedy rooming house, street prostitutes, in jail or dead.

Most will leave care without having completed even basic education (in most cases not
having attended any meaningful formal schooling since around Grade 5), have no skills,
an abnormal and mentally-debilitating body-clock/daily life/sleep pattern and as regular
drug users. The only life they will understand is a life full of manipulation, fear, having
treated the workers in the units as their pseudo servants/semi-slaves for years (drive me
here, give me food, shut the fuck up) and without an ability to communicate
effectively or respectfully with most people they come into contact with. Most will have
no ability to hold a job or continue meaningful, further study.

We are producing drug-ravaged, semi-literate, brain-numb members of a violent US-style


social underclass with almost no understanding of how to treat other people with
empathy, kindness, patience, care or love (including their children/future children).
From the Notes:
Andrew told staff to fuck off! I aint waiting an hour to go see me mum! XW
demanded a pair of scissors which staff had already told him he was not to have
as he wanted to cut off the plaster that the doctor had put around his fractioned
arm only yesterday. Andrew tried to run into the office, Xavier blocked him and
writer got off the computer and also blocked the door. Andrew got highly escalated
and punched staff member Xavier two or three times before violently shoving him
against the office door and wall. Andrew threatened Xavier saying Ill kill you
cunt!. Xavier managed to push Andrew back against the wall and turned to walk
back in the office. The writer yelled, look out mate but it was too late, Andrew
delivered a hard punch but it missed Xaviers head and landed on his shoulder.
Xavier was forced to turn around again to face Andrew, this time Andrews hand
hit his cap and knocked it off. Xavier walked back toward the office and Andrews

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

last swing completely missed as Xavier entered the office and we locked the door.
Andrew threatened Xavier with more violence at a later date.

_______________________________________________________________

24. Recommendations:
Incidents in Resi care as a Preface to the recommendation.
The main suggestion I will put forward relates to staff-child ratios.
Most incidents in units that do most damage to property or to other people are due to the mix
and numbers of children in the units.
This property damage, staff stress leave/sick leave and compensation costs millions of dollars.
Most conflict and incidents are due to things like:
-

One child needing to act tough or show off in front of another child.

A new, younger or weaker child being abused/bullied by others who see this as an
opportunity to show whos boss or gain some power and control in the unit.

Children getting new residents/younger children to set up staff or abuse staff to


show that they are cool and can be tough too.

Conflict with other children caused by being affected by alcohol/drugs.

In view of the above, I have a recommendation that would reduce violence and abuse in
units by up to 80% or 90%.
My suggestion, if implemented, would also reduce costs to the Departments/State Governments
by a huge amount due to a reduction in property damage of up to 60%, a reduction in staff
stress/sick leave of around 60%, a reduction in costs associated with
violence/police/ambulance/courts of around 60-70% and a reduction in power and unit running
costs by up to 50% 4
From the notes:
Norm began to escalate calling staff member Johan a cunt. Johan told
him that we will not put up with that behaviour and closed the door. Norm
immediately began to yell and scream saying that he is going to kick
Johans car. Writer heard Norm go outside so writer ran out and physically
blocked him from attacking Johans car and Johan then came out too. Norm
picked up a chair over his head and threatened to hit writer with it. Writer
stood his ground and Norm walked away into the kitchen threatening to kill
4

Currently, most Resi units cater for up to four young people. I dont know about other States, but in Victoria, most
purpose built DHS houses are absolutely horrible, cold, disgusting places; the opposite of homely or of a warm,
caring environment.
They are very large and the waste of electricity in these very houses is extreme. Children leave lights/utilities on all
night in almost every room.

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himself and then began to scream in pain. Writer investigated and


discovered Norm holding his hand and grimacing [he had hurt his hand and
wrist by punching the wall]. Writer got some frozen peas and a tea towel.
On the way to the hospital, Norm apologized to writer for his behaviour and
thanked me for taking him to the hospital. He told writer that he cannot
control himself once he gets angry and he doesnt know what he is
saying...
From the notes:
...Angus later told me that Leon has been in Angus ears and inciting
violence against him. Angus said he does not feel safe and is on guard all
the time living in a constant state of stress and fear for his personal safety.

Principal recommendation (Recommendation One)

I propose that:
Each Resi child is placed in a purpose-built, physically beautiful, modern two-bedroom
townhouse with two staff at most times. 5
This recommendation is based on the realities of what occurs within the current situation and,
crucially, some actual examples of where single-child and double-staffed units have been
trialled.
Why a modern, beautiful small residence?
-

Because these are our most vulnerable children, who have been deeply damaged
and traumatised. They deserve the best we can provide, not the third or fourth best
6

A small, modern home would be more homely, would offer a warm and
caring/nurturing environment and the child would live in an atmosphere different
to what they were used to when growing up in squalor and poverty. Currently, the
physical conditions for many Children are not much better than what they were
removed from.

Of course not all Resi children are the same. Thus, a non-violent seventeen-year-old who is attending TAFE full
time, rarely takes drugs and is not abusive/violent towards staff, could be accommodated differently than a
sociopathic, violent 14yr-old.

A few years ago, a rural State backbench MP spent around $50,000 on a study trip to Paris to better understand
and appreciate the way public libraries operate in Victoria''. Her report concluded: ''When comparing public libraries
in France to those in Victoria, you would have to say we are very well served. Our libraries are much better
equipped when it comes to technology, although collection size is probably comparable, as is floor size.'' If State
MPs can be so profligate on taxpayers money for overseas study trips that serve absolutely no useful purpose for
anybody or anything, then surely, we (society as a whole), can spend what is required to help to heal children in
Out of Home Care and provide the best for them? (ditto re the money Victoria has spent subsidising the Grand Prix
car race over the years (almost one Billion dollars).

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Why children by themselves?


This is the crux of the whole issue of the dysfunction relating to how Resi care currently
operates and of this recommendation.
At least 90% of all incidents of violence, bullying, abuse, staff assaults and police call outs, are
due to the fact that the children are with other children - with whom they have no relationship
but who are also from similar backgrounds and with similar issues/problems.
It goes without saying that:
-

A child cannot be bullied and abused by another child, if they are not with that
other child.

Two or three children cant gang up against another if there are not three or four
children in a unit.

A child cannot set up a newbie or weaker child to abuse a staff member, slash
their tyres, scratch their car or attack them physically if they are not with that
other child.

A child will not have the need to act tough or show off in front of another child
by carrying out bullying, aggressive or violent acts upon another child or staff
member (or damage property) if they are not with that other child.

A child (particularly of just 10/11/12-years-old) who has not been exposed to


drugs, will not be in a position to so easily be exposed to drugs if not living with
hard core drug users whose number one priority is to get the newbie on drugs.

Why two staff members to each child? (this would be for most situations but not all)
I know it can be hard for people with no experience in Resi units to understand how powerless
staff are. Currently, the children have almost all the power and rights. This is not positive for the
child as they are not learning anything about responsibility or how to get on within or survive in
normal society.
In short, some aspects of how we treat young people have come too far one way. These children
know all about their rights but wish to accept no responsibility for anything and have almost no
ability to respect others rights (including staff members right to be treated with basic respect as
human beings).
Out in the real world when they are eighteen and onwards, they will be alone out there they
will not have the power they now have in Resi units. They will not have staff who have to act as
semi-slaves to them, who they can abuse and assault but still expect that their meal will be
cooked, that they will still be taken to get their take-away on Friday night, still be given their
pocket money and that the staff member will have to clean up the mess the child makes when
they throw all the food around the house because they are upset or angry about the Staff member

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having said no to an unreasonable or impractical request or that their Mother cancelled their
access visit at the last minute for the third month in a row.
So to get back to the recommendation: Most incidents that involve violence against staff and
against other children are because of the simple fact that there are multiple children in the unit
and that often one staff is alone with two, three or even four young people.
If there was one young person in a unit with two staff at most times, this would change the
power imbalance that currently exists. The adult staff would regain the power which is how it
should be.
I am not talking about power in an old-fashioned sense of a 1950s Catholic boarding school,
giving kids the strap or literally washing their mouths out with soap and water. In the modern
world, with properly qualified staff, hopefully we would be talking about caring professionals
who would essentially be trying to provide a homely, caring and, dare I say loving environment
but where there is a proper balance between the childs rights and responsibilities.
This means that the adult staff would have most power (which is how it should be). I am talking
here about normal parental type power such as the power (the fundamental right) to tell a
child when to go to bed, when to turn off the TV, what to watch or not to watch, how loud to
have his/her music (including in the car) and that it is time to get up to have breakfast and
(hopefully) get ready to attend some educational program or even an actual school without
being viciously abused or even assaulted.
Having two staff at most times with just one child by him/herself, would reduce assaults against
staff to almost zero. It would reduce to absolutely zero abuse/bullying/violence by one child
against another and reduce property damage by up to 80/90%. This would result in a reduction of
all incidents in Resi units by up to 90% or 95%. In turn, this would reduce police call outs by
hundreds per year and other associated ambulance, police and court costs. In total, millions of
dollars from the DHS Residential Care budget would be saved.

From The Notes

Patty was visiting with her mother when the writer arrived this afternoon.
Patty appeared to be in a good spot when she returned. Once Patty and
Chloe got together they became very abusive and derogative towards staff
member Gaby, calling her such names as whore, slut and calling her a
prostitute. The writer tried to keep things in a nicer content but this only made
the girls more abusive towards Gaby. Chloe said that she was going to tell
her father about Gaby and that she will get him to come and kill her. This
behaviour has been going on now for nearly three hours. Staff have tried to
disengage from the girls on a number of occasions, each time Patty has put
her foot in the door preventing staff from closing it and both girls threaten
Gaby with physical harm by telling her that they were going to smash her
head in and at one stage Chloe actually spat twice in Gabys face.
As Gaby was using the phone to call on-call, (both staff were at the door
preventing the girls from entering the office but unable to close the door

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owing to Pattys foot being in the way), Patty snatched the phone out of
Gabys hand and before she could take off, Gaby grabbed it back off her.
Both girls then stated that Gaby had hit them but the writer had witnessed the
whole episode and Gaby did not once lay a finger on either girls.
Once the girls were informed that police were going to be contacted they both
left the unit on foot, returning about 30 minutes later. Chloe apologized to
Gaby about slagging in her face but the verbal abuse still continued. Fred
(on-call) decided that it would be best at this stage to replace Gaby with
another worker for the Sleepover. Once the girls were aware that Gaby was
no longer on sleepover, they stated to writer that they were happy that they
had won and that Gaby was leaving because of them.
From The Notes

Danny and Mick were in the side yard of the unit when they both started
yelling abuse and threats toward people that were in the backyard of the
Girls Guide Hall next door. They were told to stop however they did not
listen even when they were told the police would be notified. Danny was
seen throwing rocks dangerously at the girls. Both boys threw crates
onto the roof of the unit and then got up on the unit roof and yelled more
abuse to the girls in the yard.

Once the units were built (or acquired and appropriately renovated), the annual running costs
(including staff employment) would certainly be much less than current. In current units when
there are major issues, or a new child arrives, there is often a Stand Up staff member plus the
regular Sleep Over staff on duty. When staff are away due to stress/sick leave after being
assaulted etc, the CSO must use Relief Agency staff. So the staff member (if permanent) is being
paid sick pay while the CSO is paying the Agency about $100 per hour for the casual
replacement staff. Many units have Agency staff working on an almost permanent basis. This
costs hundreds of thousands of dollars per year.
Additionally, in a structure based on this recommendation, when a new child comes into the
system, these relatively innocent young children would not be subject to bullying and violence
and not exposed to sexual abuse/exploitation by older, more hardcore children or to drug use in
an immediate sense. Over time, this would also reduce drug use in Resi care by a large amount (I
would estimate by up to 50% or 60%) and obviously child-child sexual abuse in units also to
absolutely zero.
The overall reduction in incidents and property damage plus a halving of utility bills would save
tens of millions of dollars per year which would probably cover cost increases inherent in my
recommendation.
Finally it is important to note that this recommendation is based on a trial that has already
occurred.
Twice in Bendigo, a child had to be placed by themselves due to sexual issues in a unit or their
violent behaviours. St Lukes (at huge cost), rented a nice, modern, beautiful self-contained
holiday unit where one child was placed for about three months and the other for about two

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months (not at the same time). That is, one child was by themselves with two and sometimes
three staff.
The accommodation was a two bedroom, very modern unit with nice prints on the wall, a large
screen TV and shiny, new fixtures. I worked with both the children.
The first child was a thirteen-year-old boy who had not been that long in Resi. He was being
heavily bullied and harassed by other children but there were also sexual issues and so he was
removed and was placed by himself.
In the other units, in part due to the stress he was under as well as trying to be tough in front of
the other children, he had changed from being a quiet and fairly respectful child to being abusive
to staff, had started smoking and so on.7
In short, the boy changed his behaviour within days. He was not verbally abusive to staff, he was
of course not stressed or on edge due to potential conflict with or bullying from other children
and he was generally calm and well behaved. No property was damaged.8
Due to being in such a physically nice environment a type of place he had probably never been
in during his entire life he felt better within himself and the whole situation provided a sense of
security and safety (ie away from the other children) plus that he was actually being respected
and made to feel a bit special (a nice, modern, clean, homely place).
The girl was a much more extreme character very verbally aggressive and potentially violent.
She had assaulted staff quite often as well as damaged property such as smashing holes in walls.
Again her behaviour changed. She did not become an angel overnight, but no damage
occurred and from memory no assaults occurred (I was not permanently on shift so I dont know
the full history of her time there) and of course, she could not bully or carry out violence against

Many children are quite well behaved when they first arrive in Resi, in spite of their home background. This is
because they perhaps actually do have expectations that they will be cared for and be living in a nice place.
However, once they arrive they are suddenly in a cold, ugly place with holes in the walls where the loonies are
running the asylum. Any hope they had of living in a nice, warm, caring and safe environment goes out the window
very quickly. These children will adapt very quickly to the conditions and will of course have the emotional need to
be accepted by their peers and therefore carry out whatever behaviour is required to be accepted. In this way, the rot
sets in very quickly. They are removed from dysfunction, abuse and chaos but put into another situation that is
equally dysfunctional, chaotic and abusive.
8

However, these units were not safe for staff. There was no lock on the staff or childs bedroom door (which was
almost certainly a case of the CSO acting an illegal manner in terms of work safety). There was nothing stoping the
young person walking into the staff bedroom in the middle of the night, assaulting the staff member, or (in case of a
female young person and a male sleep-over staff member), entering the bedroom in the middle of the night and then
alleging sexual misconduct. This type of dangerous and unsafe environment for staff is quite common because of the
stupidity and lack of concern on the part of CSO Resi management.

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other children. I distinctly remember that she actually did some art and craft activities and
expressed pride in keeping her bedroom tidy. This was genuine, positive change in just days.
Again, I strongly feel that, for the most part, this was due to the same reasons given above for the
boy:

she felt good and special about being in a nice, modern place

the power balance changed in favour of the adult carers and

conflict with other children was reduced to zero.

In other words, being in a nice, clean, homely, caring and warm physical environment plus by
herself and with two staff, reduced incidents, issues, problems and violent incidents by around
95%.
Additionally, she was able to enjoy other activities that she wouldnt have done in the usual units
(such as the art activities), precisely because she was by herself. In a normal unit, with two or
three other children around, she would be too busy getting into conflict with them or with staff to
even think about sitting down to do an art or craft activity. Even if she wanted to, she would not
have done so; such an activity would not be seen as cool amongst the other children and she
would have undermined her tough and bullying persona. Without the other children around, she
was free to be herself.
This recommendation (based on real situations) is very logical.
The way that changes occurred and the reduction in incidents and violence was inherently
consequential of the physical change and transformation of the power imbalance.
From the Notes: (a Tuesday [ie most regular kids would have school the
following day]).

Kevin left the unit at 11:15pm and returned at 12:37am presenting as being
substance affected. He was in a very heightened state and displayed
hostility toward writer and was trying to kick in co-client Susans door. He
was screaming threats to Susan and this went on for some time. During the
night, Kevin squirted dishwashing liquid all over the floors around Susans
door and ran around the unit screaming and slamming doors, banging on
the office door, playing loud music and yelling out profanities, Kevin was last
heard at close to 6am.

The costs associated with property damage would also be reduced by up to 80% or 90%, as most
of this damage results from situations where one child is showing off and being tough in front of
another child or due to conflict with that other children or with staff.
With two staff members, this potential conflict and the children blowing up over any issue (eg
having received a bad news phone call) could be reduced by a huge amount as two staff would
be there and in a position to fully and comprehensively monitor the child at all times and
professionally and adequately support each other and handle the situation to stop it getting out of
control.

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Recommendation Two:
Until such time as a better, more peaceful and healing structure is put in place such as based on
my recommendation for all children in Out of Home Residential Care, no new young person be
placed with other young people from this point forward.
In the case where the boy who broke all the windows, this was a therapeutic unit with three
young children of 10/11 years-of-age. They were not mixed with harder-core older boys of
sixteen or seventeen and were mostly attending school and not taking drugs. Despite this, their
behaviour was atrocious. The unit was still full of violence, misbehaviour, and staff assaults.
This was mainly because of one boy (the one who broke the windows), having an extreme desire
to control everything and everyone around him, with no empathy, no patience and other
sociopathic- like personality disorders related to whatever his history of family abuse/neglect
was.
So his behaviours were always going to make a smooth-running, peaceful, harmonious and
healing environment impossible. He bullied the others or ganged up with one against the
remaining child (ie two against one).
Take away this dynamic caused by the boys being together and, abracadabra, almost like magic,
up to 90% of the incidents in that unit would not have occurred! Yes, it is this simple. It is
inherently rational, logical, commonsense and simple.
In many situations based on my proposal, you would not in fact need all units to be double
staffed. The staffing would be on a case-by-case basis. Double staffing would not be needed for a
child attending school and who is generally well-behaved. For example, if the little plastic bag
boy I picked up from DHS had been placed by himself from the word go, all that happened to
him in just a few weeks, would not have occurred! Im sure he would have been fine with one
staff member. So, the cost involved in having one child with two staff, would, in fact, not need to
be the reality for many children. So it would be a false cost projection if the number of Resi
children was simply multiplied by two to arrive at the basic staffing costs for my proposal.
Double staffing would be needed for perhaps 60 percent of children but certainly not for all.

From the Daily Notes:

Trystan is knocking at the office door at 12.40am and asks for a bottle of
water. The writer explains that she had asked if there was anything he
wanted just before lock down and that she wasnt going to be getting back up
to get him anything else so if he wanted anything he needed to ask now. He
seemed to be just toying with the writer making me look for things that werent
even here, which he knew and thought was funny. He was back at the door
with Flynn at about 6.20am and seemed to be bright and wide awake. He was
babbling on to the writer about how he and Flynn had been awake all night
writing rap songs about Jaydan. He said in the lyrics they talked about slitting
Jaydans throat. The writer told Trystan that that is not funny and that he and

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Jaydan have been getting on OK so why start picking on him now, just
because Flynn is back. When Rebecca arrived for shift she also noticed that
Trystan seemed pretty lively for someone who had been up all night and she
asked him if he had taken anything. Flynn told staff that he and Trystan had
taken ice and this had kept him awake all night.

Recommendation Three
A properly designed, holistic and integral alternative educational system needs to be urgently
put in place for the thousands of children in out of Home Care who are currently not attending
any meaningful education or, in fact, none at all and living half their days on drugs and in a
chaotic, violent environment.
Of course such facilities already exist for disengaged and at risk youth, but need to be
expanded to accommodate hundreds more children and for these children to be attending for a
full day. We need to get real and stop treating these children as poor little traumatised kids
who we cant possibly expect to concentrate for more than an hour at a time and who couldnt
possibly attend a full, proper educational program. If they can concentrate on playing computer
games for hours and hours at a time, travel around to all sorts of places all over the State when
they have absconded, they are perfectly capable of attending a properly-designed, fun,
interactive, hands-on, creative and dynamic alternative education facility to be known as a
Dynamic Healing and Education Centre. They need to be legally made to attend or if they dont
(or misbehave), be sent to a secure Dynamic Healing and Educational Centre (similar but more
holistically designed than the current secure welfare) where they would stay for up to three
months at a time off cigarettes, off drugs, not abusing staff, learning and getting their body
clock and brain back into a regular routine.
(See attached proposal for these Healing and Education Centres)
Recommendation four (following from the previous)
A properly designed, holistic and integral alternative secure welfare system needs to be urgently
put in place for the thousands of children in out of Home Care who refuse to carry out basic and
reasonable requests, assault staff, refuse to attend school and are heavily involved in drugs
including selling drugs and getting new Resi kids onto drugs.
These are the children we have let slide into an atrocious situation. It is not really their fault,
but by letting them just take drugs three times per week (or more), abscond for days at a time and
not attend schooling, we are producing semi-literate, drug-zombified, violent members of a
deepening underclass.
This is not good enough for a rich, developed, creative nation like Australia.
We cant turn back time. Most of these kids will not change very easily. The idea is that we must
get them off the streets and stop them going down their path of self-destruction.
Just like we sometimes place people who have had an acute psychotic episode or a nervous
breakdown into a secure State-run psychiatric institution, so too we should place these children

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in a secure welfare situation, but for as long as required. This must be seen as a mental health
issue and could be achieved through amendments to the Mental Health Act and/or other
legislation relating to State Guardianship of children.
Many of these children have been in and out of the current Secure Welfare facility already, but,
for most (like many prisoners in real jails), they come out and after a few days or a week, go
back to their same violent and destructive behaviours. This is because they are put back into
same dysfunctional Resi unit where they carried out their act of violence or dangerous activity in
the first place.
From the notes: (This was during a normal school day. None of these
three school-aged boys were attending any schooling).

TU has been bickering at PQ trying to bully him and PQ is mostly


ignoring it. Afterwards TU was wrestling with RS and PQ which ended
up with PQ upset and he put a hole through the plaster wall in the
lounge.
From the notes at a girls unit. A normal school week.

When writer locked the unit at 11pm the three clients were in GHs
room. None of them would say good night to writer or make any eye
contact. Writer could not tell if they were substance affected but GH
wanted a pair of scissors before she went to bed. They played loud
music, ran around the unit, slamming doors, banging and yelling out for
most of the night. From 3.15am to 3.45am someone was banging on
the office crimsafe door, without a break. Writer did not respond. The
noises slowed down around 4am and seemed to have stopped by
4.30am. When writer checked the unit this morning at 7.30am there
was food, dishes, cups and papers on the back patio table and some in
the kitchen. Writer checked the pantry door, which had been locked by
writer but it had been forced open.
Another night at the same unit:

After the unit had shut down all three girls remained up. At about
12:40am the writer could smell something burning, the writer went
outside to the patio where all 3 girls were and found the burning smell
to be the strongest there. The writer asked what had been burnt OP
kept saying nothing and that it was all in my head. The writer kept
asking what was burnt. OP told the writer that they tried to burn some
rubbish in a big container not realising that the container wasnt fire
proof and as soon as the container started to melt they had put it out.
The writer reminded OP that I take lighting fires seriously and that if
they light anything else on fire that I will have no option but to call the
police. The girls remained rowdy but not distractive but were still awake
well after 3am. In the morning the writer did another look around to find
what had been burnt and found that the girls had put some paper in a
flower pot, which is now badly burnt and melted.

We need to build (or reform) the current secure welfare model where we can place such young
people who are under our care for up to three months or even longer. The first thing they do

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wrong when they come out (refuse to attend school, assault staff or carry out some other violent
or criminal act), they will go straight back for another three months (a sort of modern version of
the old reform school)
It would not be known as secure welfare but rather a Dynamic Healing and Educational Centre
[secure]. The main purpose would be to get these kids off drugs and start them on a path to
education and healing. If two lowly-educated drug runners can set up and run such a place in a
rat infested jail in Indonesia, then surely Australian State Governments can design and run such
a facility!?
We need to do better than simply allow hundreds of young people under our care to be
wandering the streets, absconding from Resi, prostituting themselves, taking drugs and not
attending any schooling or education. We are their parents. They are children who deserve
much better than what we are currently providing them under our so called care.
True love and care needs boundaries, rules, mutual respect and a proper balance of power as well
as rights and responsibilities. We need to provide tough love to these kids. Our current care is a
complete joke, as there is no commensurate balance of power, respect, fear of any consequences
for acts of violence or property damage and not even basic respect or fear of police. They need
control and order in their lives. Even if this requires special legislation to provide the Minister to
personally mandate rules and regulations for units and expectations of behaviour, plus the
consequences for not doing so, then this should be considered. The Minister should consider
acting as the Parent, because the delegation of this legal parental role to DHS and the CSOs is
not working (this is an understatement).
From the Notes (snippets from separate days in the same week about the same young fourteenyear-old male not attending school.
AB remained up calling writer a liar and demanded Milk. When writer told him
there was no milk left, AB escalated quickly, getting in writers personal space
and threatening to hurt and kill him. He again threatened to hurt writer who
withdrew to the office....
...At about 5:20pm writer heard some yelling coming from out the front of the
unit, writer went to investigate to discover AB and CD out the front of the Girl
Guides Hall next door in a confrontation with an unknown male. The man drove
aggressively at the two clients spinning the wheels and swerving in an attempt
to run them over. CD threw a garden stake at the vehicle but missed. The
driver then swerved and knocked over the unit bin as he took off. When police
attended the unit, ABs body language was jittery, he could not stand still, his
sentence structure was messy and his pupils were huge. Writer believes he
was substance affected. The police interviewed him about the incident and he
admitted hitting the man after the man hit him first. ABs exact words were I
smashed the fuck out of that cunt. The Police gave AB a lecture about
behaving himself but AB just thought everything was funny...
... AB seemed in a bad space when he eventually got out of bed, but he was
pleased to hear that staff had organized a Drs appointment for him as he is still
feeling unwell. His complaints range from headaches to chest infections and he

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

believes he requires anti-biotics. Writer suspects that his body is so run down
because of his constant drug abuse...
...AB appeared to be highly substance affected. His pupils were dilated like
dinner plates and he was bouncing off the walls and saying how he plans to
bash JK one day soon after shut down when no one is watching and get coclient BY to cover for him. When writer asked what he and JK had done for the
day AB told writer they had got tipsy as well as got high. AB stayed up until 5
am laughing and talking to unknown female on his phone as well as having BY
go in and out of his room. Writer was disrupted by AB a total of twelve times
during the night.
...I was forced to pull over after he whacked me in the shoulder and threatened
to jump me for the car
...Then he turned to staff and started accusing Fred of trying to trick him, he
ended his rant by saying you cunts are lucky I dont jump up and down on your
heads
...ABs behaviour has again displayed a high level of aggression and being
unpredictable
...AB eventually went into town with his girlfriend Antonia but returned
quickly, out of breath and extremely escalated, yelling that he had just bashed
his friend Paul. He said he has had issues with him for a few weeks and that
they had just had a fight in the street...

Modern, holistic, caring, loving, creative, colourful, playful, interactive, physically beautiful
integral healing and education centres integrating healing professionals, teachers, art/music
therapy, outdoor activities, sports, health and so on, need to be set up as a matter of urgency.
I will shortly send through an idea about the structure for such facilities which can be added to
this Report. Of course there are people with much greater expertise than me about such
alternative educational settings and many years experience of such places being in existence. So
we would not have to completely re-invent the wheel and we should learn from best practice
overseas as well. For the most part, the alternative schools that exists for at risk students are
lowly funded, in physically poor shape and have to scrounge around for materials and resources.
I am essentially suggesting to use this existing expertise and the experience and passion of the
teachers and staff at these schools but tweak what they offer for Resi kids but in new, speciallydesigned centres.
Recommendation Five
I recommend that that most children in Resi care are not provided pocket money as cash-in-hand
for the reasons described in the body of this report. Either the money is spent with the Carer on a
range of approved items, put in a Trust Fund or in a cashless card that cannot be used to purchase
certain designated items.
I recommend for older children receiving Youth Allowance: that this is paid into an account
controlled by the CSO and that it is spent with the carer on approved items including phone
credit and so on.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

The provision of pocket money and Youth Allowance that for many children simply goes to
purchase drugs from sleazy drug dealers, many of whom are also involved in other criminal
activities such as sexual exploitation, is insane.
Recommendation Six
Almost all Resi children smoke. Many of these children get their ciggies in the form of filthy,
used butts picked up in the gutter or out of bins and ashtrays.
As a matter of urgency, this issue be designated by the State/Territory Ministers as a very high
health priority area for children in Resi and a holistic plan is designed as to how to reduce
cigarette use and abuse by these young children in our care. Their bodies and lungs are being
damaged by tobacco during their developing years including in the pre-pubescent years for
thousands of these children. For sure, this is not as crucial as ice/weed abuse or the educational
issue, but it is not good enough for this issue to not even be on the radar because it is just
accepted by the CSO and the Minister that Oh well, these type of kids are going to smoke,
theres nothing we can do about it.
Finally, as a harm-minimisation practice, it would be worth exploring the possibility of providing
at least the youngest children who do smoke but who get almost all their cigarettes as discarded
butts from the gutter, with say four clean, proper cigarettes each day while a strategy is put in
place to ween them from their habit completely.
Recommendation seven
I recommend that whatever funding is required to fix the dysfunction in Resi be found or redirected from other funding to ensure the children are provided proper care, love and support,
education, health and healing.
Victorian Premier Daniel Andrew stated a few days ago that it would be OK for Victoria to
increase debt in a responsible way to fund vital infrastructure such as rail and roads. This is very
true.
However, social infrastructure is more important (or at least equally important) as railways and
roads, submarines, jet fighters or MPs study trips to Paris, Istanbul or Peru. Regardless of the
amount required, the Government must find whatever amount is necessary to ensure we are
providing our abused and traumatised children the best they deserve and by doing so, massively
reduce the violence, drug use and social decay as described in this report.
This must be a high priority for Government spending. $1 spent now will save $9 in the future.
And as explained above, millions would be saved by my recommendations in any case.
I recommend that the relevant COAG Ministers chaired by the Prime Minister should meet asap
to discuss this crucial (albeit somewhat hidden) social issue affecting our nation. Remember,
there are around 40,000 children in Out of Home Care Australia-wide and a large percentage are
Aboriginal children. If we can extrapolate the reality in Victoria to Australia wide as well as my
approximate statistics, then of this 40,000 children, at least 20,000 (but more likely 25-28,000)

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

would be in a situation of not attending any purposeful education on a day-to-day basis and
taking drugs, behaving violently against other children or staff, sexually abusing other children
and damaging property on a weekly basis and absconding from care on at least a monthly basis.
Lets stop the rot, the social decay, the drug use, the brain decay and the violence that is being
created by the status quo related to the dysfunctional system in place for children in Out of Home
Care.
From the Notes:

Due to not buying the right two-minute noodles, Kamren verbally abused staff
members Fred and Jack but also pushed both of them. He called Fred a Fat, lazy
Dog and threatened to smash him. Kamren went outside and Fred heard him
kicking the car door...
...At approximately 9:45pm, writer discovered that the rear door of the unit was
again unlocked but pushed closed to make it look locked. Writer also noticed that
all clients were being very careful while going in and out of Kamrens room. With
co-worker as support, writer opened Kamrens door catching them unaware.
Leyhton had a pair of scissors in a bowl and they were about to chop up some
cannabis. Writer could not gain full entry to the room but believed there to be an
extra person in there. Writer asked the clients to remove the drugs from the unit.
They stated that they would go somewhere else to smoke it, showing both staff
members a small bag of cannabis and a glass bong. They also had another male
with them, possibly the same one that they snuck in the other day. Writer told
Leyhton that he could not leave the unit because of his 8am-8pm curfew but
Kamren and Haiden distracted staff at the door while Leyhton snuck out. Staff
have made sure the back door is again locked but fear the clients must have a
special trick to open it.

From the Notes:

As Writer was finishing up the night, I heard a noise coming from ABs room at
11:30pm and it did not sound right, so I went to the office door to see what was
going on and AB and BC were fighting and very violently punching each other in
the face for about five minutes. Writer tried to stop them by getting in between AB
and BC and got hurt by one of them accidently...

We should be ashamed that we have allowed such a broken system of care that is in fact
harming thousands of children and carers every day to have continued for so long.
SO, I URGE this Commission to recommend to the Federal Government as a matter of absolute
priority and urgency that a Federal Royal Commission be established to examine Out of Home
Care in all its dimensions and to make recommendation relating to (in particular):

drug use and abuse


daily routines/sleep patterns
violence
education (the lack of)

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

instability of placement
The establishment of new, alternative and properly-funded and resourced holistic and
integral schooling and secure welfare centres (Healing and Education Centres) that are
urgently and desperately required and that the children must attend and be forced to
attend.9

Yours sincerely,

Phil West
Dr Phil West, Ph.D
March, 2015
Endnote:
In a section of his book To Have and to Hold when describing the launch of The Alannah and
Madeline Foundation, my co-founder Walter Mikac wrote: when its my turn to address the
crowd, I tell them that the idea for the Foundation came from a Melbourne Father, Phil
West...and shows how one person can make a difference.
I am proud that my idea to honour the lives of Walters two children murdered at Port Arthur
inspired many people at the time to take action.
I had a vision that became a reality through creative thinking, idealism and unity of action on the
part of many people who supported the idea and helped to make it happen. I hope that another
dream I have, can inspire people of goodwill and people in positions of power to act relating to
the crisis in Out of Home Care in Australia.

I can recommend a simple way to pay for the entire infrastructure needed. Simply reduce the number of
Joint Strike-Force Fighters we are planning to purchase from the US (72) by six and this would provide
$1.2 billion (each fighter costs approximately $100 million plus a further $100 million in maintenance). The
reduction in the number of fighter jets from 72 to 66 would not make the slightest difference to our
national defence but provide enough funds to pay for new Out of Home Care infrastructure plus staff
costs for a number of years.
Liberal Party backbencher, Dr Dennis Jensen, the highest qualified scientist in Parliament, has
condemned the purchase of the fighters as a great national scandal and worse than a disgrace. While
I am not advocating not purchasing any of them as Dr Jensen is, a reduction of just six would provide for
the proper care of our nations most vulnerable children and the building of the required social
infrastructure without State and Territory Governments having to borrow or find money from existing
budgets. The infrastructure cost is a once off. The massive reductions in the general running costs of the
new units if my recommendation was accepted would mean the new facilities (and staffing structure)
could be run at around half the current cost - even allowing for higher salaries for more highly qualified
staff.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

My dream is that the Australia I believed in when I was a small boy in the 1970s can be realised
a proud, safe, peaceful and developed country where all have an opportunity to excel and
prosper. A country where our most vulnerable and traumatised children are seen as at least as
important in terms of State and Federal Government funding priority as submarines, Jet Fighters,
the Grand Prix and, of course, MPs study tours to Paris.
Currently, we the adults educated in the 60s and 70s who run our country are turning a
blind eye to drug use, violence and almost a complete lack of education for thousands of our
collective children who reside in State care.
We can and must do better than allow tens of thousands of children in our care throughout our
country to grow up becoming either violent, semi-literate, unskilled, drug-affected bullies and
sociopaths or semi-literate, insular, drug-affected victims of bullying and sociopathic violence
unable to function properly in daily life, living on welfare and having children who will grow up
to be the third or fourth generation of that family leading a similar life.
Thousands of these children will carry out violent robberies and house burglaries, random
assaults and bashings and become heavily involved in drug and other crime (too many already
are at the ages of just 12/13/14). This is not good for them or for the innocent victims of their
crimes. It is not good for our nation.
We need to stop this social decay and the further development of a violent, drug-ravaged social
underclass that will affect us all. The time to act is now.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Appendix A
Daily notes from the units
These are copies of Daily Notes written by the carers at the coal face in various residential
units over a period of around two years.
All identifying details have been changed or deleted to ensure no breach of confidentiality. All
personal names, including names of police officers and DHS personnel have been changed and
in some cases gender identity has been changed. Dates have also been removed.
All place names have been changed or have been replaced with a blank line and all shop or
landmark names have been changed or replaced with a blank line. The only ones not changed are
very general ones such a McDonalds or Coles. In some cases, even these have been changed
from say Coles to Woolworths or McDonalds to Hungry Jacks.
No ordinary member of the public or even the children concerned would know who is being
discussed.
It must be noted that the type of incidents reported in these notes happened, and continue to
happen, at most Out of Home (Residential) Care Units throughout the State every week.
Hundreds of current or ex-child Residents of these units reading this could easily say this
sounds like me or this sounds like what happened in my unit.
I was given these notes and the cut and pastes from the Incident Reports on a USB by someone
at the Head Office of the CSO for whom I was then working when I had dropped in about
something. They wanted me to help them put a Power Point presentation together for a PD or for
a course they were doing or something similar.
I have highlighted small parts of text illustrative of drug use, violent or abusive behaviour,
emotional status or other notable issues in red or occasionally with yellow highlighter. Please
note that at times there are longer sections with yellow highlighter. These longer parts were in
the original notes and I was not able to undo the text highlighting.
I also occasionally intersperse the notes with comments which relate to my main submission
and recommendations.
The time-line of the notes has not been cut and some excerpts present a number of weeks worth
of daily notes. This provides the reader with a sequential understanding of the lived, daily-life
existence in Resi units over a reasonable period of time.
The only other editing is in terms of some grammar and syntax. The notes are written in a
pressured situation and without this editing, some sections of the notes would have been quite
difficult and frustrating to read.
Each separate segment of notes is separated by a three line division.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Unfortunately these real Resi notes do not make pleasant reading. Many professionals from the
areas of social work, counseling, child psychology, the medical fields plus journalists, legal
practitioners, judges, Royal Commissioners, academics, students, religious groups, Members of
Parliament, educators and ordinary, concerned citizens will be disturbed and taken aback at what
these notes reveal.
Essentially, they reveal a broken, dysfunctional system in which conflict, violence, extreme
verbal abuse and bullying, physical assaults and bashings, property damage and drug use are an
almost daily occurrence in most Resi units. Most shockingly, they reveal that an almost complete
lack of more than just tokenistic education or meaningful emotional and psychological healing is
provided to the children who have been placed under our collective care.
Many children are much worse off in many areas of their lives than they would have been if they
had stayed in their dysfunctional and violent or abusive families from which they were removed
by the State.
These are our children who we all have collective responsibility for. If the State has made the
dramatic decision to remove children from their families, then the State has the legal and moral
liability to provide what these children need in terms of emotional/psychological healing and
care, their educational needs and most crucially, a safe, clean, warm and healing living
environment.
This legal and moral responsibility is currently being completely and fully abrogated for at least
80-90% of children in Resi care in Victoria (and almost certainly throughout the rest of
Australia).
I believe that this submission will be the first that has provided clear proof of this in terms of the
daily life in the units. This Royal Commission provides me with a legal and moral framework
to tell it as it is and to tell the truth to power without fear or favour. When I found these notes
on an old portable hard drive, the idea to publish them did not initially enter my mind. It was
only after skim reading them that I realised they would provide a perfect appendix to my report
and recommendations, as they clearly present a practical illustration of the issues discussed and
the commentary in my main report in an uncensored, direct and detailed manner.
If this submission does not lead to a serious intent to change the system from top down (perhaps
according to my recommendations [but I am NOT saying that I am the suppository of all
wisdom {apologies to the PM}]), then I would hope that some of the largest legal firms in the
land consider taking legal action on behalf of current and former Resi children. Potential State
compensation for emotional and physical harm, educational neglect and in other areas made clear
in my report and exemplified by these notes, would no doubt be worth Billions and such a legal
threat may be the only way State Governments will take this matter as seriously as it deserves.
There have been many reports in the past outlining many of these issues and even dramatic
headlines. However, after two days of headlines, a report on PM; or the 7:30 Report and a
Ministerial investigation, everything goes back to form. Essentially nothing has improved over
the past 20 or more years under both Labor and Liberal Governments.
These are OUR CHILDREN. This is OUR SHAME.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Tuesday
The writer picked Penny up from the Shop at about 19:35hrs. On the way back to the unit Penny
told the writer that she didnt have a very good day at school today and when the writer asked
her what had happen to make it that way she said that she had been bullied at school and the
principal wouldnt help her, saying that she was no longer at primary school and that the way it
goes in high school. The writer told her that if she feels that she is being victimized, to talk to
staff. Back at the unit Penny had her dinner, asked a few things from staff such as ironing the
creases in her skirt and putting her clothes in the dryer. Penny was in bed by 2010. Roslyn
Wednesday
The writer took Penny to school at 850am where on the way, Penny explained that she may be in
trouble today for hitting a girl and possibly giving her a blood nose. The reason for Pennys
actions was because the girl, who is in her class, called her a Black Dog which caused Penny
to react by hitting her. Penny explained that the principal told her that retaliation was not a good
response and she should not have hit her. Penny expressed that hitting this girl was not right but
said that how was I not meant to retaliate to someone calling me a Black Dog? The writer
suggested talking with the principal about what happened if she gets in trouble for hitting her.
Penny returned from school and asked for a drop off and appeared to be in a good space,
although when Penny went into her room she said her room was hot and she would smash the
window if she cant open it. Writer gave her bus money and Penny left. Penny rang for a pick up
around 17.20 hrs and when she returned appeared to be in bad mood, claiming she is bullied at
school and is sick, that she is doing too much and needs to slow down. Penny would not wait for
dinner to be finished and cooked herself bacon and cheese sandwiches. Writer explained to
Penny that in future when she reverse charges to the unit they will not be accepted because of
high reverse charge bills and staff will ring her straight back on her mobile, Penny
agreed. Francis
Penny came back into the lounge at 9.45pm and stayed watching TV until writer turned TV off at
10.30pm. Penny wanted to stay up but writer suggested she needed to go to bed anyway. Penny
stayed on the couch until approximately 11.15pm then went to her room. Annafrid
Thursday
Penny was woken at 7.35am, she got up and showered and got ready for school. Writer made her
some lunch and drove her to school and praised her for making the right decision about going.
Penny phoned the unit at10.20am asking for juice drink to be brought to the school, she also
stated she still felt sick and didnt want to stay at school. Writer encouraged her to hang in there
as she may get a reward for attending school all week. Penny said she will see how she goes.
Annafrid
Cont Writer on shift at 8:30. Penny called for a pick up from school at 11:00am. Picked up by
writer and she complained about racial abuse at the school and also being picked on for being a
resi kid. She said words similar to: Theyre fuckin racist cunts and You cant be a resi kid and
go to that school.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

At 12:20, she left to go to her Mums to talk to her about all this shit. She then rang at around
1:10 cancelling optometrist and medical appointments saying she wants to Mum to go to both,
but her Mum is not able to today. She stated she would return later or call for a pick up. Al
Cont- Penny called for a pickup at 7.40 from in front of _______. When she returned to the unit
she was substance affected and went into bathroom and vomited into sink, Writer asked Penny if
she had been drinking or smoking marijuana. She admitted to drinking, which could be smelt
from her vomit. Welfare checks were done every half hour. Penny spent the rest of the evening
in her room. Shavonne
Friday
Writer got up at 7am and was still in her room Writer tried a number of times to see if she
wanted to go to school but Penny said nothing, Penny got up at 12:30pm looking very sleepy and
sat with staff for a bit and then believed Penny got a salad for lunch and then went to her
room. Rudiger
Cont Penny was up and about again between about 1:30 and 3:10, when she left the unit on
foot promising to be back later. She was very dressed up. In the unit, she had been polite, asking
politely for snacks and drink and interacting nicely with staff. Al
Penny rang up for a pickup outside DHS at 22:30. She informed the writer that she had been at
the movies with her friend and has a new boyfriend Roger who is the same age as her.
Penny returned to the unit and made herself noodles, joining staff and co-clients to watch the rest
of step up 4, Good choice tonight Penny on returning to the unit. Mariah/Roslyn
Saturday
Penny was up at 9.30am she said that she slept well. Booked Penny into have her eyebrows
waxed and a haircut. Penny and writer went to appointment. Penny was extremely happy with
her hair cut. Writer dropped Penny at mums house in ___________ street. Penny said she will
probably get a bus home. Writer reminded her about the 1800 reverse charge calls. Penny told
writer she had a new boyfriend in ___________ who was the same age as her. She said they
went to the movies last night to see ___________ and showed writer the movie stub. Penny said
that the boyfriend was her age. No more details were given. Penny was polite and nice to be
around all morning. Writer dropped Penny off at her mums house at 1.45pm. Penny came home
later, spent 5 minutes in Janes room, then had dinner with staff and Jane, then went to her
room. She went out a bit later and then called for a pick up at 6.15pm Shavonne
Sunday
When writer arrived for shift at 5pm Penny was out; she had left earlier in the day with co-client
Jane. Roslyn (staff) picked up Penny and Jane at 6pm and on return to the unit had dinner, stayed
in the lounge for a while and went to her room approximately 9.30. Writer gave her a milo and
she said good night for the night. Annafrid
Monday

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Penny was up at 8.30am, she watched a movie, had breakfast then phoned her mum asking if she
could visit today. Writer dropped her at ___________ St (where her mum is staying) at
11.45am. Annafrid
Penny has been in a great space this evening. Penny mentioned to staff she does not want to go to
school tomorrow. Staff asked if everything was ok, Penny said she has a few issues and did not
want to talk anymore. Paula
Tuesday
Penny did not go to school this morning. Staff are not to drop Penny at her mums unless mum is
called first, this is due to Penny going to _________ St unit instead of being at her mums. Penny
has requested she wants to go to rehab. Penny asked Tammy to send her to rehab but Tammy
explained to Penny that there is a process involved when going to rehab. Penny was not happy
with Tammy and said she could get fucked. Tammy organized for Rosemarie to come out and
have a chat, Penny was content with that. Rosemarie will be attending Pennys care team
meeting on Thursday. Paula
Cont
Writer picked Penny up from ___________ st with co client Jane around 20.45 and returned to
the unit. Penny said she would go to school if we ironed her pleats on her school skirt, writer did
this. Penny had a bag full of new things (clothes, picture frames etc ) that she said her Dad had
bought for her. Francis
Wednesday
Writer woke Penny up for school and Penny got out of bed and asked for some snacks for school
and a bottle of water, writer offered her a prima and snacks and her pocket money to buy a bottle
of water. Penny then said I dont want that shit and youre not my mother, you cant tell me
what to do and refused to go to school. Penny went to her room and then left the unit around
10.50 am on foot. Francis
Cont. Writer picked up Penny from ___________ Street at 1840. On the drive back to the unit,
Penny said she was angry at Mum for not trying harder to find a new place. Once back at the
unit, Penny stayed in the kitchen talking to staff about school and Mum and how hard it is to give
smoking weed. We talked about this and Penny said she would go to school in the morning,
Penny stayed up and watched a movie and then went to bed around 2330.
Thursday
Penny was up at 0700 this morning, Penny was in a good space and was talking about trying
harder at school today. Writer did notice that she was shaking quite a bit. Penny walked to
school.
At 1030 Penny called from the school to say that she was not coping and needed to come home.
Writer spoke with Tammy and then went up to school. Writer sat with Penny while student
services spoke with her. After an emotional discussion it was decided that Penny return to school

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

tomorrow and attempt to start half days. Penny broke down again about living in Resi and
wanting to move in with Mum. Writer and Penny returned to the unit, Penny settled and watched
a movie in the lounge room with co-client. Mariah
Cont
Writer took Penny to her care team meeting today. Tamarrah (mum) was late and Penny was
very anxious about that. It was discussed during the meeting about Pennys time table for school.
Amij from _______ College has provided the unit with a new time table for Penny: 6 full days a
fortnight and the rest half days as her drug usage inhibits her time at school and she has asked to
go to rehab. Rosemarie informed Penny that staff here at ________ st can give Penny
supplements to help with her drug issue as this it would be a better option than going to rehab
and would be exactly the same as rehab. It was also discussed about Penny going to mums one
night a week for stay over when mum gets her own place, and maybe a placement with an Uncle
here in ________ rather than at the unit. Penny left the meeting with her mum to go
shopping. Francis
Cont;
Writer phoned Penny just before 8pm to see if she was ready for a pick up from her mums as
she was having dinner there. Penny stated she was just eating dinner now, writer said she would
pick her up at 8.30pm which she did. Penny said she was getting a tattoo tomorrow and her mum
was paying for it. Writer asked if this was happening after school, Penny said she didnt want to
go tomorrow but wanted to start afresh with her new timetable on Monday. She stated she would
phone the school tomorrow and discuss it. Penny became a bit moody when she asked for a coke
at 9pm and was refused. Writer spoke to her later she said she never gets what she wants here.
Writer suggested this wasnt the case, Penny seemed in a better mood a bit later but went to bed
around 9.30pm. Annafrid
Friday
Penny did not attend school today. Staff phoned the school to inform them. Josefina called to
inform staff she is trying to find an alternative placement for Penny and she will keep staff
updated on this. Paula
Cont;
Penny has mentioned that she may go to ________ today and stay overnight with her mum. She
states her Cousin has passed away. Writer reminded Penny if she is going to do this to keep in
touch with the unit by phoning them when she arrives in ________ . Staff will also phone her in
the evening to do a welfare check so that we can inform DHS that we are in contact with her
while she is away. Penny stated she thinks she will only be away for the night and that her and
her mum may stay in a motel. Annafrid
Cont;
Penny stated she was leaving the unit at 1pm. She said she was going to ________ whether her
mum went or not. Writer tried to speak more with her but Penny was impatient to get going and

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

seemed upset. Penny also stated she has a friend in hospital in Melbourne and may have to go
there. Writer reminded Penny again to keep in contact with the unit as to her
whereabouts. Annafrid
Cont.. Tammy has informed the unit of possible places Penny could be staying in ________ .
Could staff please inform after-hours as a return to placement warrant will be issued. Penny has
lied about her cousin dying, Tammy has confirmed this.
Cont
Writer has rung Penny for welfare checks at 19.50 and 20.10 and both times it was engaged.
DHS to be notified. Francis
Friday cont:The writer contacted DHS After Hours and spoke with a Rizza who said that she will look into
her file and will ring the unit if they have plans on doing anything tonight. Roslyn
Saturday
Writer telephoned Penny and she was in good spirits, Penny said that she was with her Nan at the
moment and the family were all together, Penny asked the writer to call her back this afternoon
to speak about something.
Writer called Penny back at 2000, Penny said she was fine and with family. Penny said she
would talk tomorrow. Writer called Tamarrah and was advised that she didnt travel with Penny
but she would be home on the lunch time train tomorrow.
On-call was contacted and DHS after hours (Donna) no need to do missing person at this stage as
YP has been spoken to by Tamarrah and Grandmother. DHS said if Penny does not return on
lunch time train to ring after hours immediately. Mariah
Sunday
Penny still had not returned to the unit by 1252hrs, the writer called Penny and asked if she was
back in ________ yet. Penny said that she was still in ________ and when the writer inquired to
when she planned on returning Penny was very vague in her reply saying maybe later tonight or
tomorrow. The writer has contacted DHS After-Hours. Roslyn
Cont.
Writer tried to contact Penny several times throughout the evening, all being hung up on. Writer
tried Tamarrah (Mother0 and received a `Fuck Off on last attempt. DHS did not ask for a return
to placement warrant. Missing person not available as we have phone contact. Mariah

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Monday
Writer tried to phone Penny at 9.40am, it rang a couple of times then hung up. Josefina (DHS)
phoned unit , writer relayed this information and she also tried to contact Penny by phone and
text. Writer phoned Josefina at 10.40am , she is checking that not having a missing persons due
to contact yesterday is correct. Annafrid
Tuesday
A warrant was organized for Penny yesterday. Writer made phone contact with Penny today
at1.35pm, she sounded in a good space, and asked if a warrant was out on her. Writer replied
yes. Annafrid
Cont
Staff had a phone call from Shavonne this evening disclosing another conversation with JM
about Pennys whereabouts. Writer rang Tamarrah and Tamarrah told writer she had spoken to
Penny this evening and she was very drunk and abusive and possibly in the company of Bec
Jones 31 years-old who resides on the high rise flats in __________. Bec is apparently well
known by police. Also could be in the company of Colin South (daughter of Bessie South
apparently also well known to police ) and Talley South step daughter of Bec who is known to
hang around the streets of Collingwood. Have contacted AH DHS with all this information and
they have documented this and are not sure if police will act on any of this information this
evening. Francis
Thursday
Writer tried to phone Penny at 2.12pm, the phone rang a couple of times then went to the
engaged signal. Annafrid
Cont. The unit received a phone call from Fitzroy police station at 7:05pm informing writer
that Penny had been caught trying to break into cars with two other females, one of the females
had chroming substances in her bag, glue etc. Penny was returned by police at 6:00 am. Paula
Friday
Penny woke up Jane at 0600 asking for Tabacco or a mix, Jane had nothing. Penny then went on
to say she bought back a lot of ice, but dropped it off at her Mums house. Penny was saying that
she stole a car and drove it to __________ before the police caught her.
Penny left the unit at 1230pm all dressed up and told writer and Jane that she was going out to
get drunk with her friends. Mariah
Friday cont:The writer gave Penny a welfare call at 1800hrs, Penny sounded fine on the phone and did not
sound substance affected. The writer asked if she was returning to the unit tonight and Penny
replied that she would be back soon. Penny called the unit for a pick up at 1843 and the writer

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

picked her up from 21 __________ Rd. Penny appeared to be in a good spot and told the writer
on the way back to the unit that she is glad she was brought back as she was missing ________
and her mother. Back at the unit Penny ate her take away and then fell asleep in the chair before
staff woke her to go to bed. Roslyn
Saturday
Writer arrived on shift at 8:30. Penny woke up at about 11:30 and greeted staff in a good mood.
Penny cooked lunch/breakfast for herself and chatted about her time away. Penny said she stayed
with her aunty in Melbourne for a couple nights. Penny talked about Thom getting out of rehab
and then smoking choof the same day. She was very disappointed and said she was glad he is out
of her life. Penny mentioned that she had been drinking whilst she was away I had a drink here
and there you know. Penny talked about seeing her mum today and maybe Rocco. Penny said
she is glad to be back at the unit and intends to go to school on Monday. Penny found a court
form and believes she has court on Monday so she wont be able to attend that day but intends to
go to school throughout the entire week. Penny was in a good space all day watching movies
with staff but she left later in the evening out of the blue. Jess
Sunday
11am: attempted welfare check p/c x 2 to Penny . No answer.
11:15am: txt msg sent to Penny letting her know the writer is concerned about her and would
like to know her location.
11:17am: P/c to Tamarrah re Penny s whereabouts. No answer.
12:15pm: P/c from Penny requesting pick up from __________ Rd. When asked by the writer
who lives there, Penny said, Just a mate. The writer advised her that when Lorraine returns
from __________ with XY, the writer would call her first then pick her up.
1:45pm: Sarita picked Penny up from __________ Rd, where she said her mate Billy H lives.
Penny said she stayed there all night and watched DVDs, but also said shed been awake until
6am. On request, Sarita took Penny to MacDonalds on the way back to the unit where she
bought her own lunch. Penny settled on the couch to eat and watch TV. Sarita
Sunday cont
At 4pm when the writer arrived Penny was asleep on the couch. Penny wakes at 5.40pm and tells
the writer she isnt feeling well. The writer noticed she didnt look well. Penny had some dry
biscuits to eat then heard her coughing in the toilet. Penny starts to watch a movie and then falls
back asleep on the couch with her doona. Staff unable to wake her to go to her room. Tammy
Monday
Writer woke Penny up at 8, as she had court at 9:30. Penny refused to get up and said she wasnt
going to go to court. At 08:50 staff contacted the ________ Court and checked up on Penny s
case, which wasnt on today. Penny was in a good mood, and got ready for school. A meeting

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

was organized at the school for Penny at 10:30 Tammy picked up Penny at 10:25 to take her to
school. Jess
Cont. Writer picked up Penny from school and she demands to be taken to the end of _________
Street where her mother is staying, Writer explains that she has to wait as there is only one staff
member on at this stage. Josefina
Cont... Penny did not return to placement tonight. Staff contacted DHS after hours. DHS
informed staff they do not want to hear about Penny absconding unless it is up to day three;
this is due to her being such a regular absconder. Paula
Tuesday
Penny rang for a pick up from __________ Rd a friends house, and told staff she had stayed in
___________ the night before at an Uncles house. Tamarrah rang from ___________ Street
saying that she hadnt seen Penny since yesterday. Tamarrah said that she is really worried about
Penny and would like her to go to Secure Welfare as Tamarrah is finding it hard to believe
anything she is saying and where she goes when she absconds.
Penny returned to the unit and had dinner, while co-clients were in Janes room smoking
marijuana. Penny complained about the smell and as she cannot open her window to let the smell
out. Penny went to her room around 22.00 Mariah and Francis
Wednesday
Penny has been cleaning her room and helped writer do the dishes. Penny seems to be in a great
mood and asked to ring Josefina and her mum. Francis
Cont. Penny left the unit at 1:50pm writer asked what time she would be home, Penny said she
would be returning tomorrow. Writer reminded Penny she has a bail curfew but this did not seem
to bother her. Room search was conducted and bong was removed from room. Penny didnt
return to unit this evening. Mariah/Paula
Cont;
It is noted in day book that on call were contacted at 10pm and DHS A/H were contacted at
10.05pm. Annafrid
Thursday
Tammy stated to writer today that police must be phoned every night Penny has not returned to
the unit as she has a 7pm 7am reside at _______ St curfew bail condition. Police were phoned
at 1.20pm today to inform police of breach of bail. Writer attempted to contact Penny by phone
with no success. Writer then phoned Tamarrah (mother), she stated she has not seen Penny since
yesterday afternoon, Penny stating she was going to a friends. I reminded Tamarrah Penny is on
bail conditions. Tamarrah said she will ask Penny to phone the unit if she hears from her.
Tamarrah is also unable to attend todays care team meeting as she is unwell. Annafrid

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Cont
Penny has not returned to the unit this evening and staff have tried to phone Penny, (phone
engaged )and contacted the police for a missing persons and breach of bail. Francis & Kezza
Friday
Penny had still not returned to the unit when writer arrived. Writer tried to call Penny for a
welfare check at 3:00pm, she hung up. Paula
Cont
Penny rang for a pick up from ____________ at 19.04, and was picked up and returned to the
unit by 17.30. Penny appeared to be substance affected, and said she had been staying in
___________ . A/H DHS have been notified of her return. Francis
Sat
Penny up and about around 8:30am, Penny wanting to go the Gym some time. Penny having
breakfast and used the phone. Jackson
Cont.. Penny has been awesome today. Writer and Penny went shopping and spent the afternoon
doing hair. Penny said she will not be home tonight as she does not want to be around co clients
when they smoke bongs. Paula
Cont. Penny was not at unit when writer arrived, by 2130 Writer telephoned Penny mobile hung
up, second call phone off.
Penny did call for a pick up at 2140, from __________ Road writer reminded Penny that she
does have a 7pm curfew from the police. Penny returned to the unit and went to her
room. Mariah

Sunday
Penny was not at unit when writer arrived, by 2130. Writer telephoned Penny but mobile hung
up, second call phone off.
After hours _________was notified of Penny not returning to the unit tonight. ________ Police
were contacted Constable Fred S took details. Mariah
Monday
4.45pm Penny has not returned to the unit yet. Josefina (DHS) phoned her today, Penny stated
she will be returning to the unit tonight. Annafrid

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Cont
Penny rang for a pick up around 19.40 this evening. Writer picked Penny up from _____ street
park. Writer asked Penny where had she been and she said she had been at a friends. Writer
asked her if she would start to stay in the unit instead of absconding, Penny explained to writer
she needs to sort her shit out and cant stay in the unit because of the dope smoking. Writer said
to Penny she cannot sort her shit out by doing what she pleased and might get herself into
trouble. Penny told writer that writer shouldnt care and its no-ones business. Penny said she
wants to get a new phone and mum would get it for her. Penny asked if it was school holidays
and writer told her it was and adding that hopefully we can do some cool activities during this
time, Penny said there was nothing cool to do anyway. Penny came back to the unit and ate her
dinner and watched a movie. Francis
Penny went to bed at about 10.30 pm. Kezza
Tuesday
Penny was up and about at approximately 9am. She had a shower and cleaned her room,
including the vacuuming. She spoke to Josefina about getting a new phone. Josefina said that
Penny could get a new phone if she abides by her bail curfew and returns to placement every
night for the remainder of the school holidays. Annafrid spoke to Penny about playing basketball
next term, and she said she wanted to. Annafrid took Penny and Jane into town to purchase
basketball clothing at about 11.45am. Kezza
Writer dropped Penny at ___________ St where her mother is staying after going to the
shops. Annafrid
Cont..
Penny rang for a pick up from the train station around 17.40 and when she returned to the unit,
Penny only stayed until 18.25 and left on foot. ________ police were contacted after several
phone calls to Penny after her curfew. Francis
Tuesday cont:DHS After Hours contacted at 2025, the writer was informed by DHS that Penny needed to be
absent 24hrs before After Hours involvement, no action from After Hours at this time. Roslyn
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________
Sunday
Writer took Rocco to the footy as he had permission from the president, writer bought Rocco
some new footy shorts and socks as BK had disposed of his old ones. Rocco was excited and was
dropped at footy at 10am. Stevie

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Writer got to the football game with 10 minutes left in the game. Rocco stood out with his
excellent footy skills. The crowd from North ________ were cheering go Rocco. As he
dominated the field from what writer witnessed. Rocco was ecstatic with a win. After the game
Rocco politely shook the hands of the losing team and congratulated them on their efforts.
Before leaving the ground Rocco spoke to a coach who told him that North ________ would
love to see him play more often as he has a big talent. Rocco said he would start to go to
trainings again Tuesday and Thursday at the North ________ Oval at 4 pm. Penny
Cont.. Writer picked Rocco up from his mums, he was in a great space. Back at the unit when co
client Ty returned home Rocco began to pick on him. Rocco told Ty he was going to smash him.
Paula/ Claudia
Sunday
AT 8.25pm Angie calls to speak to Rocco and AB on speaker phone re the bullying to Ty. Rocco
didnt seem to take the call very serious. Rocco along with AB were calling Ty a snitch and he
was the one who dobbed to staff about them smoking dope. Angie told him that he was the one
not very long ago that was bullied and he didnt like it. At the end of the call Rocco did tell
Angie he will stop bullying Ty. Tammy
ContRocco was dressed in his entire North ________ football gear and was kicking the ball
with Pauley across the road, Once AB returned he joined them and they all had a good kick
together. On return Rocco was pretty puffed. Rocco was in and out of the unit all day today
spending time with AB and his sister Jane and their older brother Tom. His mood was up and
down and later on in the evening presented as being substance affected. Pete
Contd
Rocco took a tent out of the unit that he said was his aunties and left with Tom (brother). He
returned a while later and kept taking food out to Tom who is supposedly homeless.
Rocco came to the shops with writer and spent some time in the unit throughout the evening
before having his meds at 9pm stating that he was tired. Rocco went to bed soon after and was
asleep by 9.15pm. Jackson
Tuesday
Rocco up at about 8.45am. He has his meds and then asks to go and kick the footy. Peter takes
him out at about 9.10am returning at 10.55am.
Rocco asked to ring Sophie but writer could not get through so we tried Tammy. Rocco spoke to
her about not feeling safe at the unit and that AB had stolen a top he had recently purchased.
Writer had already told him not to let people in his room but he had replied he is too nice.
Rocco discussed going to access with his mum early and Tammy said she would chase it up for
him. Rocco also stated to Tammy that if they did not sort out somewhere for him to go then he
would abscond to his uncle Fred in _________. Rocco has two suitcases, some fishing gear
packed ready to go. Jackson

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Cont... I arrived at the unit at 8:30am, I offered to go kick the footy with Rocco. We kicked the
footy for a solid two hours and had a good chat about the direction he wanted his life to go in and
the direction it seemed to be heading in due to choices he was making. Rocco and I arranged to
go kick the footy again tomorrow if staffing arrangements allowed, he seemed very happy with
that. Rocco told me that Caleb has been in AB ears and inciting violence against him. Rocco
said he did not feel safe and was on guard all the time and living in a constant state of stress
and fear for his personal safety. In the afternoon when we were once again kicking the football
Caleb , AB and Jane came over for a kick, everyone seemed to be having fun and I was very
aware of the bullying allegations Rocco had made, but they all seemed to interact very well. I
arrived back at the unit after seeing two co-clients to the bus stop. Staff member on duty
informed me Rocco had punched a wall and had most likely sustained a fractured hand. Writer
stayed with Rocco while staff member arranged at transport him up to the hospital. Ice pack was
applied. When Rocco came back to the unit he ate some food and then at 3:45pm the other boys
turned up, I was surprised to see him slip into AB room with Caleb after all the allegations he
had made about these two clients bullying him. Pete.
Tuesday
Rocco was across the road retrieving a ball from the tree with some assistance from a worker
next door at the Girl Guides hall. He was dressed in his footy gear; once he came back to the unit
it was obvious that he was not in a good space demanding to talk to Tammy , co-worker told him
that we are currently waiting for Tammy to call back and that he will have to wait. He began to
escalate calling writer a cunt writer told him that we will not put up with that behaviour and
closed the door, he immediately began to yell and screaming saying that he is going to kick
writers car which was still in the driveway was the garage door was closed and writer had just
arrived, writer heard Rocco go outside so writer ran out and physically blocked him in the
driveway from attacking his car, writer called for co-worker who came out to help. Rocco turned
around and went back into the house screaming that writer is trying to stop him from going to
live with his mum, writer said that this is not the truth and Rocco picked up an old wooden chair
over his head and threatened to hit writer with it, writer stood his ground and Rocco walked
away into the kitchen threatening to kill himself, Rocco then began to scream in pain, writer
investigated and discovered Rocco holding his hand and grimacing. He had punched his hand in
anger into a wall. Writer got some frozen peas and a dinner towel. On the way to the hospital
Rocco apologized to writer for his behaviour and thanked me for taking him to the hospital, he
told writer that he cannot control himself once he gets angry and he doesnt know what he is
saying.
At the hospital he asked writer to do the talking for him, writer explained what had happened and
it was not long before Rocco was called in to be examined. He yelled and flinched when the
doctor touched his hand, the doctors were surprised that Rocco said that it hurt on the opposite
side to what he hurt and questioned Rocco, in the end the x-rays were inconclusive but they said
that there may be a small fracture at the base of his hand. Rocco threatened to rip a half cast off
and demanded a full cast; they compromised giving him a half cast with some extra tape around
it. On the way home Rocco asked to be taken to see Tammy at ________ St, We met Tammy
out the front of _________and she explained that he does not have permission to go to his mums
until Thursday which is his planned Access. Back at the unit Rocco interacted well with staff and
clients which all seem to be getting along well. Rocco asked to have nuggets for dinner which he
cooked himself; he was very polite eating dinner with staff even though other clients did not.
Straight after dinner however he began to ask for drop offs to his mums, again staff told him that

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

this would not be possible, again he began to escalate calling staff dog cunts and demanding
that we call Tammy , On-Call and his mum, staff did try to call his mum but there was no
answer. He soon left with AB , Tom (ABs brother) and Caleb. Pete
Cont..
Phone call by Stevie (worker) to On-call and then DHS after hours to inform them that Rocco
has not returned to placement. DHS called back to get more details after 11pm and called again
at 11:40pm.
Logan from DHS asked if he had been at placement last night and what time he left. Writer
informed her that Rocco had gone off with Tom and had been at the unit the night before. Logan
said that if he comes back to call After hours and if not call the police if that would help but left
it up to writer. She also asked that DHS in ________ be called tomorrow to inform them that he
did not return. Billy L
Wednesday
Writer arrived at 8:30am this morning, at 9am Rocco walked in the door, writer told Rocco that
staff had been worried about him and could he commit to staying tonight at _________ Street.
Rocco said he would spend the night at _________ Street; he did not appear to be substance
affected, told the writer he has stayed at his uncles house in ___________ and spent the night
playing PS3 video games. Rocco had something to eat; staff retied his sling and elevated his
fractured arm. At 10:30 ABs older brother arrives, requests a phone call which was denied.
Rocco decided to walk Tom to the phone box to make a reverse charges call at 10:38am. Rocco
returned to unit at 12:35pm. At 1:44pm, Pete opened the office door and was talking to Caleb
(client) asking him if it would be O.K. if Caleb would go to his doctors appointment half an
hour earlier so they could get home and take Rocco to his mothers house. Rocco told staff to
fuck off I aint waiting an hour to go see me mum Rocco demanded a pair of scissors which
staff had already told him he was not to have as he wanted to cut off the plaster that the doctor
had put around his fractioned arm only yesterday. Rocco tried to run into the office, Pete
blocked him, writer got off the computer and also blocked the door, Rocco got highly escalated
and tried to force his way in again and in frustration punched staff member Pete two or three
times before violently shoving Pete against the office door and wall. Rocco threatened Pete
saying Ill kill you cunt. Pete managed to push Rocco back against the wall and turned to
walk back in the office, The writer yelled, look out mate but it was too late, Rocco delivered a
hard punch but it missed Petes head and landed on his shoulder, Pete was forced to turn around
again to face Rocco, this time Rocco s hand hit his cap and knocked it off. Pete walked back
toward the office and Roccos last swing completely missed as Pete entered the office and we
locked the door. Rocco threatened Pete with more violence at a later date. Writer gave Rocco 10
minutes to cool off and then left the office to debrief with Rocco. Rocco told writer to fuck off
and writer said he would happily do so as soon as Rocco told him how he was feeling, Rocco
said sad and writer sat down with him for a chat, At the end of this conversation Rocco
apologized for his behaviour and wished he could walk away when escalated or get some
much needed anger management counselling organized. Pete.
Comment: The child is asking about anger management counselling. He shouldnt have to do
this. This and many other types of psychological/healing/therapeutic counselling should be a

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

central part of all childrens care plans from as soon as they enter State guardianship and such
care programs/activities should be on-going, mandatory and integral to their care.
ContAfter todays incident, writer avoided Rocco partially, when we did interact Rocco was
polite. Rocco asked again and again to go to his mums, Pauley was contacted then his mum but
his mum had plans for the evening.
Rocco appeared substance affected before dinner eating a large bowl of noodles plus some
roast beef and potatoes, after dinner Rocco was very quiet and asked to be taken for a drive to get
and ice cream, writer agreed and YTA worker Zoe took him for a drive. Pete
Thursday
When writer was walking to unit they spotted Rocco decked out in his Essendon gear, having a
kick of the footy with 3 male staff members. Rocco was in a great head space coming over the
writer and greeting them with a hug. Writer got Rocco ready to go to his mums for a few days,
making sure he took all his medication. Rocco was excited to be having access with his mum this
weekend. Rocco rang the unit at 9.25pm to thank staff for taking him to his mums earlier. Writer
was impressed with Rocco s thoughtfulness. Later in evening staff decided to room search all
rooms and found co clients had urinated on Roccos bed as well as wrote in red marker on his
wall, Rocco is gay. Penny
Comment: Urinating on a bed is quite extreme and abnormal behaviour. This type of behaviour
helps to illustrate the issue of education. It is understandable that children with such types of
behavioural problems would not have the ability/emotional stability to fit in to a mainstream
school. Thus purpose-built alternative schools as per my recommendation must be designed and
built for such children for a program that is all day, everyday. It is not good enough to be
providing an education that is either completely nothing or 1-4 hours per week of tutoring,
playing games, climbing ropes or planting vegies in some piecemeal alternative so called
educational program. They deserve the State as Parent to spend whatever is required to enable
them to receive an adequate education. This is more important than roads, rail tracks or MPs
study tours to Paris to study public libraries or to Spain to study accidents by two wheel
motorised vehicles. It is simply about priorities. Our most vulnerable, damaged and endangered
collective children should be the number one priority for any government spending.
_________________
Saturday
Rocco is at his Mums on an access visit till Monday
Monday
Rocco on access at Mums.
Writer called Abigail at 10.20am and left a msg regarding Roccos pick up today.
Writer called again a little later and she said they were catching the train back from ________ at
4.10pm and she would get Rocco to call the unit for a pick up at about 6pm. Jackson

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Cont
Rocco called at approximately 6:45pm asking to be picked up from Abigails house. Writer
picked Rocco up. Abigail and Rocco said that they both had a good time in ________. Abigail
informed writer that she had given Rocco herbal sleeping tablets as he had ran out of medication.
We returned to the unit at approximately 7:25pm. Rocco appeared very tired however asked if he
could be taken to emergency to have his hand re-plastered. Writer and Rocco attended
Emergency Department. Rocco had his hand re-plastered. When Rocco and writer were driving
home, writer had to undertake a breathalyser. Rocco and the police offcier, F. Smith, recognised
each other. The Police officer said that he needs to speak with Rocco and asked writer to pull
over to be the independent person. Rocco was extremely tired from ________ and we wanted to
make it chemist so the officer said he will contact Rocco at _________ Street another time.
Rocco returned to unit at approximately 8:50pm and were too late for chemist. Rocco spent time
with AB and Caleb and went to sleep. Rocco went to hip hop at _________ last Wednesday
(4pm-6pm). Rocco mentioned he would like to continue this and attend there again this Wed if
possible. Charlotte
Tuesday
Writer saw Rocco opposite a house in ______ St where AB was having an argument with the
residents, Rocco seemed to be in a good mood running up to the car to say hello. Later back at
the unit Rocco appeared to be substance affected, he was extremely hypoactive and bouncy, he
was very alert and his eyes were large, writer suspects that he was affected by amphetamines.
He was in and out of the unit all night and seemed to be doing favours for AB getting him drinks
and lighters etc. he did not eat his dinner at dinner time but said he will be back to get in to
it. Pete
Wednesday
Rocco was up and dressed for footy at 7:30am, he was in a great space and was really looking
forward to playing football in Melbourne today. Pete
Cont when writer came on shift Rocco was out the front off the unit with Caleb and AB they
came into the unit to say hi, writer went into the unit folding washing and Rocco asked if we
could go for a drive which we did. We drove to ___________ had a look around they came back
to the unit at 8.30pm Rocco was in a good space ask if he could use the units mobile Rocco was
told it had to be on speaker phone and was not very happy about that. Rocco then started to call
staff names but when writer reminded Rocco that he had asked if writer could take him fishing in
the morning he quietly walked up to his room and didnt want to use the phone. Rocco asked
writer to open his room door which writer did then Rocco asked for his meds at 9.30pm and went
to bed. Alain
Thursday
Rocco is up early today as he would like writer to go fishing with him 8.00am. Connor
Cont.. Rocco was in a good space for most of today, he is still looking for his football that Fred
R gave him and cant find it, he suspects that the other boys have kicked it away. We got

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

permission to go pick up his steel cap boots and work pants from his mums for the bike repairing
workshop but when he couldnt find his pants at his mums, his mood changed. He demanded we
go back to the unit but because we were already running late writer said no. This made him
angry and on the drive he started making threats toward another guy that was going to be at the
program. Once we got there it turned out it was cancelled anyway. Later he went into town with
AB, they were last seen heading toward ___________ . Pete
Rocco arrived home at 11.10pm and appeared substance affected. His eyes were glassy and red
as well as his speech being slow and an overall feeling of him being out of it. Writer informed
Rocco of the alarm and he quickly ran out saying he would be ten minutes as he wanted
McDonalds. Rocco returned ten minutes later with food from the shop. Rocco went straight to
bed. Writer got the vibe that even though he may have been substance affected, he also seemed a
little down. Penny
ContRocco was acting suspicious today, writer witnessed him walking out the door with
something large stuffed up his jumper, it was so obvious that writer made a joke calling him
pregnant, shortly after staff decided to spend time with clients outside. Freddy D was also there
and refused to leave the property so staff watched him closely as they all played on their
scooters, all except Rocco who now was now being very protective with his backpack. He
eventually left with AB and Caleb and Fred D but he was back shortly after by himself and
presented as being very annoyed. Rocco has suggested to get some tackle from Kmart for his
activities with Alain tonight, Rocco s was again acting suspicious in Kmart and writer noticed
him looking at a fish gripper that was no longer in its packaging, when it was time to leave he
rushed through the registers after paying for a head torch and some tackle, once outside of the
store he walked away from writer very quickly, writer witnessed him put his hands down his
pants and remove an object and put in his bag, writer believes the object to be the fish gripper,
staff should know that this item is metal hook on one end and a clamp with gripped teeth on the
other end. Once back at the unit he spent time in his room before requesting McDonalds for his
takeaway. Rocco had a large Big Mac meal for dinner. Pete
CONT When writer arrived at unit Rocco was waiting for writer to take him fishing, we went
to _________ and where back in the unit at 11.00pm Rocco had his meds and went to bed
11.30pm. Zach
Saturday
Writer arrived for shift at 6pm to find Rocco with YZ, Jane and AB at the front of the unit.
Rocco had dinner and left the unit at 6.25pm with Tom. Rocco rang for a pick up at 8.40pm,
writer picked him up from __________ road. Rocco presented well and he came back to the
unit, writer informed him that he could play football in the morning and he was very excited
about this. He went and got into his football gear and had his meds and went to bed at 10.10pm.
Stevie
Sunday
Rocco was up at 7am today very excited for his day of footy at __________, writer kicked the
footy with him for a bit and then drove him to South ________ footy oval where they were all
meeting before going to __________. Writer spoke to the coach (Carter) and said that they could
drop Rocco back at the unit later. Stevie

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Rocco returned a very happy man after having a win at the football and kicking a goal. Writer
told Rocco his mum wants him to call her when he gets home to organise tonights access. Rocco
said he wanted to hang out with AB for a while and have some lunch first. Once AB left the unit
Rocco was ready to call his mum. After a few attempts she did not answer the phone which
slowly started to elevate Rocco. Initially he forced his way into the office and through to staff
bedroom, taking an already confiscated bong which staff got this off him. He then got the mop
which was being used to clean at the present time and started smashing it against the house,
eventually snapping it. Rocco also repeatedly smashed the front door with his feet. Writer tried
again to get through to Abigail with no response. Rocco told writer there was no point going to
his mums or rehab as he would rather smoke bongs all day. Rocco continued to pace around
the house, kicking in doors. Staff disengaged at this point. After a while Rocco slumped
himself on the floor in the hall way and looked very forlorn. Writer went and sat with Rocco
to let him know she is there. After a while he asked why his mum wouldnt be answering. From
there they had a chat which seemed to calm him a little more Ella
Continued
Rocco was upset when writer arrived for shift at 4pm as he couldnt get his mother on the
phone. Writer had called Abigail many times only to get her message bank. Writer sent Abigail a
txt message regarding access with Rocco. Rocco came food shopping with writer buying a few
things to take to his mothers. Around 6.15pm Abigail had called the unit stating she was ready
for Rocco to come over. Peter dropped Rocco off at Abigails. Later in the evening Rocco called
the unit for his meds to be dropped off. Writer knocked on the door, after a while Rocco
answered. Rocco was in great space. Claudia
Monday
Writer has not seen Rocco this morning as he spent the night with his Cousin Claudia
Cont
Writer picked Rocco up from his Mums for the ______ program at 9.50am, Rocco was
showered and in a great mood. Writer dropped him at the program and picked him up at 12pm,
writer then took Rocco and his Mum to his care team meeting at 1pm.After the meeting we went
to the hospital where Rocco got an X-ray on his hand .The doctor said the results showed he had
a crack in his bone on his hand .He said this should heel up in about two weeks if Rocco can
keep his hand in a cast. Rocco said that he didnt want a half cast because he would rip it off
straight away when it stinks. They did a really good job in putting his hand in a cast and making
the colour of the cast purple which Rocco was happy with. Writer also purchased a shower cover
for his arm so that he wouldnt get it wet, Rocco was happy with this and said that he would keep
it on his arm for the two weeks. Writer then dropped Rocco and his mum back at her house, it is
arranged that staff can pick Rocco up from his mums house late after dinner. Stevie
Cont writer picked Rocco up from his mums at 10.00pm Rocco had his meds at mums before
we came back to the unit 10.30pm Rocco said hi to other clients then went to bed
10.45pm. Alain
Tuesday

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Writer arrived as Rocco was leaving this morning for a trip to Geelong where he was expecting
to enter a drug and alcohol treatment program that is 14 days in length. Rocco seemed in a
relaxed mood and the writer wished him well and congratulated him on his courageous choice to
enter treatment. Pete.
Cont.
Writer received a call from Rocco who was looking for Pennys phone number. Writer said that
he didnt have her number. He then asked for his Mums number which writer gave to him.
Rocco sounded well over the phone and happy that he was at detox. Writer put the detox number
in the unit phone number listings. Stevie
Wednesday
Rocco is in Detox in Geelong.
Thursday
Rocco called at 2:20pm and informed the writer that he was going to be returned to the unit at
7pm tonight. Rocco informed the writer that he had told detox staff that he would harm another
client if they didnt get him out. Rocco was happy to return to treatment next Tuesday. Writer
called Tammy, and Rosemarie to inform them of Roccos decision after calling Detox to
confirm. Detox informed me that it had been Roccos decision that if he was not taken home,
relationships between himself and another client may escalate. Pete.
Comment: This child spent one day in detox and he decided he didnt want to be there after all,
so he uses the same behaviours that he saw and learned in his dysfunctional and violent family
and/or in Resi threats of violence or actual violence - to get his way. So his bad behaviour is
rewarded. He gets what he wants.
He was 14 years-old at this time. He was taking weed about 3-5 times per week and other
substances (chroming, ice, amphetamines) 1-2 times per fortnight. As I said in my report, if we
can involuntarily detain adults (or children) who have had acute psychotic episodes in secure
psychiatric facilities via the Mental Health Act, then we also MUST involuntarily intern
children, who at 13/14/15/16 already have a hard-core drug addiction, in holistic detoxification
/healing facilities for as long as necessary to break the link between State care and drugs,
violence, dysfunction, crime and hopelessness and start a true healing and rehabilitative process
to enable them to function as normal human beings.
Such facilities would of course be holistic in that they would include full educational, physical
ed/outdoor ed, art, music and sporting facilities. In other words it would be like the Dynamic
Healing & Educational Centres as per my recommendation but for child and teen drug
addicts/potential addicts. Each child would be in a small unit with two staff (like the new Resi
units as per my recommendation) and come together with the other children for the daily
activities/educational programs. At 6pm, they would be in the units by themselves with two staff
for dinner, relaxation and bed-time routines. There would be certain security type staff for
potentially violent children. In other words, the cycle of violent and abusive behaviours that they

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

are used to in current Resi would be not tolerated. The children would stay up to six months in
these facilities if necessary.
_____________
Cont
Rocco came back to the unit at 5:35pm with John (Worker) and was very quiet. Writer said hi to
Rocco but he did not respond. After having a good talk after dinner Rocco wanted Writer to call
AB. Writer said to Rocco why and Rocco just said to let him know he was back from Detox.
Writer called AB and said Rocco was back but AB was talking about other things and AB said to
call back latter. Once off the phone Rocco said where is AB and Writer said he didnt know but
down the street somewhere and Rocco said to ring him again and Writer said he was doing stuff
plus Writer just got off the phone. Rocco then said he wanted to be dropped off down the street.
(comment: it is clear that Rocco wanted to get drugs from AB another hard-core drug user
whose own brother and mother were included amongst his drug providers [which was known by
the CSO and the police]).
Cont Writer said that cannot happen at there is not drop off plus it is just past 6pm Rocco then
said to Writer: I am going to smash you if you dont drop me off. Writer said to Rocco its
not my rule but nothing Writer said to Rocco made a difference and Rocco said that he was
going to light paper on the wall on fire. So Writer got up and seen Rocco lighting the paper on
fire and Rocco was just smiling as it was burning. Rocco then went outside. Writer then told
Claudia (Worker) and then rang on-call and was notified to call the police. During the calls,
Rocco was banging on the office door and then went outside and was hitting the windows yelling
abuse towards Writer. When the police arrived, Rocco was calm and then Police talked to Rocco
then staff and they said to ring them again if Rocco plays up again. Claudia spent most of the
night with Rocco in front of the TV then Rocco had his Meds and went to bed. Rudiger
Friday
Rocco is up at 9.15 am, writer dropped him at tutoring at 10am. Writer informed him that he had
a new worker and that he was going to ICMS. Writer informed him that that only change he will
see is that his new worker Freddy W would possibly be able to spend more time with him. Rocco
rang writer at 11am and asked for Freddys number as Pat was picking Rocco up after tutoring.
Rocco arrived back at the unit at 12.15pm with Pat and some Maccas. Rocco had a shower.
Saturday
Rocco went to access in the morning. Rocco phoned a few times asking that Stevie go and play
footy with him. Rocco was told that while he was on access he needed to play those things with
other people as staff could not come and play with him.
Rocco sounded ok on the phone. He phoned a little later and asked if writer could ask AB to
meet him at the station (comment: for another drug pick up). Rocco did not phone again after
this. Jackson

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Sunday
Today at 5pm writer called Rocco to see what plans were for the evening as he was still at his
Mums house. Abigail informed writer Rocco was out playing football with friends and would be
back soon. Rocco called back at 6pm and asked if he could stay at his mums one more night.
Rocco is spending the night at Abigails. Ella
Monday
Writer called Bec to organize a pickup for Rocco and she said she would get him to call when he
woke up.
Writer received a call from Daisy stating that they had organized another night of access for
Rocco.
Rosemarie was contacted and she said she would pick Rocco up tomorrow to take him to
detox. Jackson
Continued,
Writer has not seen Rocco today as he is still on access with his mother. Claudia
Tuesday
Writer has not seen Rocco today. It is said that Rocco is at Detox for the next three months
Claudia
Thursday
Rocco called the unit to see if his room had been packed up yet, writer informed him that it had
not. Rocco then happily chatted with writer and co-worker Stevie for a few minutes, informing
them he is not enjoying detox as he is craving and is also thinking he wants to return to the unit
rather than continue at rehab.
Friday Rocco called today, writer spoke to him and he sounded happy. Pete
Saturday Rocco rang to let us know he was going fishing in a boat today. Alain
Sunday
Writer got a call from Rocco from Detox wanting to come back to the unit Writer said why and
Rocco said I dont want to say. Writer said try to stay there and call the unit any time for a talk
and Rocco said he did not want to do that but come back to the unit and smoke bongs and then
said good bye and hung up. Writer called Detox and spoke to a worker and said that Rocco
wanted to go fishing and that they said that they could not do it and Rocco started to get upset
and said that he will smash up the Detox house. Rocco called the unit again and asked who is
on? Writer said Stevie and I and then he said that can someone come and get him. Writer said

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

that cannot happen as we have three clients and one unit car and Rocco then asked do you want
me to sleep on the streets? Writer said no and then Rocco said that he will then Rocco said
see ya and hung up the phone. Writer gave some time and then rang back Detox and said what
Rocco was planning and they said when he has been upset they turned Rocco around and but
tonight he is playing up and that they said that they will try to get him back to the unit but was
not looking good since there was not much staff on. Rudiger
Comment: the notes I have stop here, but from memory, Rocco was returned to the unit 1-2 days
later when transport was arranged. In other words, his stay was completely voluntary. Im sure
that the facility as legally constituted could only deal with children under this circumstance and it
at least positive that Rocco agreed to go in the first place. In summary: at his first stay in detox,
he demanded to be returned or else he would bash some fellow young person at the facility. He
was picked up the next day. The second time, he threatened to smash up the facility and was
duly returned to the Resi unit a few days later. The first thing he would have done back in the
suburb or town was to meet up with another Resi kid or a community drug dealer and get some
weed or amphetamines. Detox for children in our care (and I would say ANY child who is a
regular drug user) should be compulsory, holistic and long-term through the mental health act.
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Wed.
AB spent time with Caleb in his room talking and playing computer games. AB informed writer
that Ty owed his $75 for a bong he broke and thinks that he will be scared to come back to the
unit because he will get bashed if he does not pay the money back. AB wanted his shoes for
the laundry at 6am. Writer got shoes but they had not been cleaned, AB put them in the washing
machine and asked that they be put in the dryer when washed. Writer said he would but it when
he did the dryer banged around a lot so the shoes were taken out. Jackson
Cont AB presented as being substance affected again tonight before dinner, again he
managed to sneak Braydon into the unit, this time AB spent time walking around the unit with
his hood pulled down so you could not see his face, going out of his way to make sure that staff
knew it was him, then he went outside and swapped clothes with Braydon F and Braydon F
walked into the unit straight into ABs room, a few minutes later AB walked in wearing
Braydons jacket. Writer did not fall for this and went straight to ABs room where Braydon F
was hiding under the desk, writer informed them that the police will be called if he doesnt leave,
Braydon agreed and swapped clothes back with AB.
AB had noodles and some roast beef and veg for dinner then went to his room to play
Xbox. Later at approx. 10:10, Tom came to the unit requesting that writer wake AB up. Writer
knocked on the door and went in to tell AB that his brother was here, by the time AB got up,
Tom was gone. AB remained up calling writer a liar and demanded food, when writer told
him that there was no milk left AB escalated quickly getting in writers personal space
threatening to hurt and kill him if he didnt go get some milk, writer explained that it was too
late and that he would have to eat something else. This was not acceptable to AB who again
threatened to hurt writer, so writer withdrew to the office. He then came to the office and
demanded food, he stated the writer plays God with food, writer said that was not true and he

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

angrily said then why didnt you go get milk earlier when you knew we ran out because you
knew I would want it. Writer explained that he did not have time. Writer offered him a number
of things and he settled for dino bites. ABs behaviour has again not be acceptable. Pete
Thursday
Writer arrived for shift, AB was in his room. Whilst writer was cooking dinner AB approached
writer and asked what she was doing. AB appeared to be substance affected being very hypo
and having large pupils. AB and Caleb then left the unit. A phone call was made regarding
another client and AB demanded to know who it was. Writer told AB the phone call did not
concern him but AB became very abusive demanding to know who was on the phone. AB
then started to call writer a lying bitch and told her that nobody was on the phone she was just
pretending. Writer and staff member Ella did a room search to find many used bags which
contained a glassie looking substance ( ice ). Police were called and attended the unit. They
found around five little used bags. AB and Caleb arrived back at the unit whilst the police were
onsite. AB was asked to empty his pockets out onto the bench. AB was reluctant to empty the
right side of his hoody pocket but continued to empty other pockets. When police left AB
became abusive towards writer calling her a mole, bitch and copper snitch. Writer shut staff
door and disengaged.. Claudia
Friday
Today AB did not arise until after lunch. When writer came on shift at 4.30pm, AB arrived home
with staff and co client Caleb from a trip to the supermarket. AB was in a great headspace,
helping unload the shopping and sorting it amongst the house. AB then made himself some food
and sat at the office door quite content with Caleb and chatting with staff. AB and Caleb went to
Fred Ds house and called to be picked up at 8pm. Whilst AB was out, writer did a room search
and found two small bags, same as yesterday. Again it had the tiniest residue left of a glassie
looking substance (ice). Writer called on call (Annamaria) to inform.
Staff took the boys through McDonalds before heading to the Cinemas where AB and Caleb
spent their activity money playing games in the arcade area. AB was well-behaved and
challenged Caleb to the air hockey and basketball. Once back at the car AB quickly made it to
the car and jumped in the front seat. Staff informed AB he needed to sit in the back. This lead to
a stand off with writer forced to sit in the cold. Writer told AB next time he asked for a favour it
may not be granted as he did not use his manners about sitting in the front seat. AB continued to
be a smart alec on the way home but not in an aggressive manner, very jovial. The remainder of
the event, Caleb and AB hung out playing video games in ABs room. At 10.20pm Staff informed
AB they could smell him smoking what they believed to be marijuana in his room and
threatened to call the police. He quickly came out as though nothing had been
happening. Ella/Shavonne
Comment: note the inconsistency of this care and what we are teaching this child in Resi. He
is caught smoking weed and also with bags that had clearly contained ice, including police
presence in regards of the ice. The next day he is taken to regular weekly activities as though
being caught with drugs is a non-issue. But, the staff member challenges the young person about
manners re sitting in the front seat of the car without asking! The drug use just continues and
continues and continues. Room searches are made, bongs or ice bags are found (albeit usually

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
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empty), police are involved but the same behaviours and drug use just keeps on repeating and
repeating. To some extent, many Resi units operate essentially as drug-dens.
Saturday
AB is up at 12 pm. AB seems to be in a good mood, interacting with staff well. Tom (brother)
arrives at the unit at 12.50pm and stays at the side of the unit talking to AB and Caleb. Tom has
respected staff and the rules at _________ st. Another young person arrived at the unit at 2pm
(Fred D), all kids hung out at the side of the unit before leaving together at 3pm. Stevie
Contd
Both AB and Caleb hung around the unit most of the day. Tom and Fred D visited and they left a
couple of times but all in all were pretty quiet and stayed near the unit.
AB asked to be dropped at the _____________ with Caleb to meet some friends. Writer dropped
them there at about 6.30pm reminding them of Calebs curfew. Both agreed they would be ready
to be picked up before 8pm.
Writer phoned at 7.55pm but both boys did not want to be picked up.
AB phoned at 8.40pm requesting pickup. Writer picked up both boys at the ___________ and
upon return to the unit they hung out in AB room. Jackson
Sunday
AB is up at 12pm and is in an excellent space, he interacts well with staff and plays his x-box
with Caleb for a bit. Tom arrives at the unit and chats with AB and Caleb but doesnt stay long.
AB received a call from a friend and then asked for his pocket money. AB tried hard to get extra
money by doing a chore. Writer told him that we dont do chores anymore at ________ st but he
gets his pocket money on Sundays if he wants. AB was not happy about this but accepted it
eventually and left with Caleb at 4.20pm to meet up with some friends. Stevie
Contd
Both AB and Caleb came back to the unit after being out with some girls at about 5pm. They
hung around the unit playing x-box in ABs room for the rest of the evening. They both
interacted well with staff. Jackson

Monday
AB got up at about midday and chatted with staff outside while they were cleaning the yard up.
AB hangs out in the unit. Jackson

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Cont
AB was in a great mood this morning interacting well, he had a shower and received his pocket
money and then left the unit with Tom, Jane and Fred D. He returned at 2.20pm and spent time
in his room throughout the day. Stevie
comment: again this was a normal school/work day. He slept in until 12pm and then is simply
given his pocket money which his carers and his CSO case manager know he will spend to
purchase drugs.
Writer started his shift at 5pm and AB was in his room and then came out to say hi to Writer and
AB was in a good space. AB spent most of his time in his room with Caleb till about 12 am then
both AB and Caleb went quiet. Rudiger
Tuesday
Writer was woken up at 6am from Clients talking. Writer went to the office door and asked
whats going on AB? and AB said that he hasnt been to bed. Then at 8:40am, writer was out in
the kitchen and AB came out to see what was going on and Writer could hear a girls voice from
ABs room. Writer asked is there a girl in your room? and AB said no and then went to his
room. Writer then went to the office and called on-call and on call was going to send out another
worker. Clients come out of room 1 (ABs room) and a young female leaves the unit with AB
and Rocco. Rudiger
ContAs writer was driving to work he noticed AB and Jane in Station St. They appeared to be
having an altercation with some people in a house. Writer slowed down and tooted and AB
stopped for a second then continued to yell at the people in the house. Writer heard the adults at
the house say your nothing but a loser kid that no one wants. AB and Caleb came up to the
car and said hello before writer drove to the unit. Later AB was questioned by the writer about
the issue and he told writer that he bashed that 22 year old guy there.
At about 5:20pm writer heard some yelling coming from out the front of the unit, writer went to
investigate to discover AB and Caleb out the front of the Girl Guides hall next door in a
confrontation with a dark-haired male driving a white ute. The man was getting back into his
car and there was a lot of yelling coming from all parties. The man drove aggressively at the two
clients spinning the wheels and swerving in an apparent attempt to run them over. Caleb threw
a garden stake at the vehicle but missed, the drive then swerved and knocked over the unit bin
and yelled out something as he took off. As writer turned to call the police he noticed witches
hats all over the road. Police attended unit, ABs body language was jittery, he could not stand
still, his sentence structure was messy and his pupils were huge, writer believes he was
substance affected. The police interviewed him about the incident and he admitted hitting the
man after the man hit him first. ABs exact words to the police were I smashed the fuck out of
that cunt. The Police gave AB a lecture about behaving himself but AB just thought
everything was funny. Pete /Claude
Wednesday

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

AB was up late today, 2pm (comment: another normal school day). He complained of a
headache and demanded panadol, the unit did not have any panadol, AB demanded some soon or
threatened to flip his shit Pete
Writer rang Walter (Worker) to see if he can pick up some headache tables on the way back to
the unit. Once back, Walter gave AB some tablets and AB went back to the kitchen to get
something to eat and then spent a lot of time in his room with Caleb going in ABs room now
and then. AB has been polite towards staff and left the unit during the day with Caleb and came
back with Jane (sister also in Resi). Jane did come in the unit and went into ABs room. Writer
said to Jane and AB that Jane cannot be on the unit grounds but that AB said Jane was not here.
Writer did not go into AB room to check as he was single staffed with four clients but could
hear Jane in ABs room. Writer rang on call (Bob) and was told to call the police if Jane did not
leave the unit. After the phone call, Writer went to ABs room again and said that Jane had to
leave. AB said to call _______ St for them to pick up for Jane. Not long after, AB, Caleb and
Rocco and Jane left the unit and Jane just waited at the front of the unit for Paula (Worker) to
pick her up and AB, Rocco and Caleb went for a walk and came back around 6:30pm. AB, and
Caleb and their friend went for another walk later and AB rang for a pickup at 10.00pm. Rudiger
went to pick up AB and Caleb and came back to the unit. 11.00pm. Alain.
Thursday
AB seemed in a bad space when he eventually got out of bed. He was pleased to hear that staff
had organized a Drs appointment for him as he is still feeling unwell. His complaints range from
headaches to chest infections and he believes he requires anti-biotics. Writer suspects that his
body is so run down because of his constant drug abuse. AB headed into town and made
plans to meet writer at the Drs in __________ at 4:50pm. Of course when writer arrived, AB
was no where to be found, so writer called him and he asked writer to cancel the appointment.
Writer could hear a lot of noise in the back ground including Rocco s voice. They requested
writer get them some drugs jokingly. Pete
Comment: Another example of how so many kids (AB in this instance), just treat the staff as
psuedo-servants and with no respect if not with contempt. He asks for a Drs appointment. It is
made, but of course he doesnt turn up despite the staff member arriving for the appointment.
Thursday continued into Friday
Writer called AB at 10.25 pm to see if they needed a lift with AB replying he would call back.
AB and Rocco arrived back at the unit at 11.10pm. Writer informed them about the alarm system
that would be turned on (so AB and Rocco said they were going back out for just ten min).
Writer waited for them and they were back in ten minutes so writer shut down unit once they
were in.
AB appeared to be highly substance affected, so writer chatted to him for an extra ten minutes.
His pupils were dilated like dinner plates and AB was bouncing off the walls chatting to writer
about how he thinks Rocco is a winge and he plans to bash him one day soon after shut down
when no one is watching and get co client Caleb to cover for him. When writer asked what he
and Rocco had done for the day AB told writer they had gotten tipsy but didnt have enough
alcohol as well as got high. Writer disengaged and went to bed however AB stayed up until 5

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

am laughing and talking to unknown female on his phone as well as having Caleb go in and out
of his room. Writer was disrupted a total of 12 times was by AB. Ella
Friday:
AB was in a good space joking with writer but again he snuck his friend Braydon F into the unit.
The kids played on their scooters showing the staff their different tricks. Staff spent close to an
hour with them before they left the unit. On return to the unit all clients appeared substance
affected, possibly cannabis. Braydon F was again with them and again on the property, again he
was asked to leave and was told that _______ will be issuing him with a trespass notice. Jane
was with them on the property, she was given a choice, she was told that I can call the police as
she is trespassing or I could call her unit and she could get a pick up. She opted to get picked up
and shortly after, Ros picked her up.
Staff and two clients later went to get take away. AB was very slow moving, his words were
slow and his eyes were red, staff had to repeat themselves a lot when communicating with him as
he was having trouble computing what we were saying. In the Fish N Chips shop writer had to
order for him as he struggled talking to the lady taking his order. He kept making little mistakes
like walking to the wrong car etc. once at the unit he spent time in his room with Caleb who was
passed out on his couch. Later the pair left the unit and called for a pick up one hour later from
the 7/11. Pete
Comment: These last few excerpts demonstrate incessant drug use and illustrate how completely
broken Resi care is from top to bottom. For many children in care, the units are just beds,
food and places to take drugs, sneak people in, stay up and sleep-in until whatever time they
want while not attending any schooling, education or integral nurturing/healing/rehabilitative
programs. The units of course also offer a regular food supply and the childrens own private
servants/chauffeurs. Oh and of course provides them their drug and alcohol money.
Saturday
Writer on stand up, writer heard nothing from AB until 5am. He got up and knocked on Calebs
door. Caleb got up and went into ABs room, writer could hear them talking quietly. At 5.30am
Caleb came out and went straight to his room, AB appeared and chatted to writer. AB had red
eyes and appeared substance affected, he went and made some noodles and went back to bed.
Stevie
Continued
Writer arrived for shift at 12pm AB was in great space. Writer was cooking lunch when Rocco
brought AB his phone. During the phone call writer over-heard AB saying that he would go
score and $5 would do but if he used his pocket money they could get more. Soon after AB
hung up and he was at the staff door with Rocco and Caleb asking for pocket money. A young
male knocked on the door and AB left and returned around half hour later. AB asked writer to
cook tuna pasta bake for dinner. AB ate nearly all his dinner Claudia
Cont

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Writer arrived on shift and Jane and Tom were out of the front of the unit, not long after Jane
was picked up by _______ and Tom left the unit with Rocco. AB and Caleb asked to be dropped
off at the ___________ which was done and they called for a pick up later. Writer picked AB
and Caleb up at 9.30pm and both presented very well, not substance affected. AB came back to
the unit and interacted well with staff and spent time in his room with Caleb. Stevie
Comment: It was so remarkable that they werent substance affected, that this was noted by
staff.
Sunday
Today AB wanted to have an appointment at the doctors. An appointment he agreed to was
made for 11.30am. AB was woken at 10.30am and 11.00am before telling writer at 11.10am to
re-schedule for later in day. Writer made an appointment for 1.10pm. At 11.25am Jane
arrived at unit stating she had just spoken to AB and he knew she was coming. AB dressed
whilst Jane waited patiently out the front. Finally at 11.40 AB was ready and the two headed off
on foot. At 12.10 Jane and AB were back, once again Jane waited out front unit. When writer
reminded him of his appointment in an hours time AB told writer to cancel again as he was
going out to spend the day with Jane. Writer told AB they would cancel and he is to inform staff
tomorrow when he wants to make another time. AB left the unit to spend time with Jane. On
their arrival back to unit writer asked Jane if she wanted writer to call _______ Street unit to get
a lift, Jane said yes. When Paula came from _______ Street AB and Jane said they were going
to walk to _______ Plaza. AB was in a great head space today happily talking to staff when he
was in and out of unit. Ella
Comment: Again staff being treated like semi-servants and chauffeurs and young person does
not have to learn anything about basic responsibility such as about the medical appointments. He
simply got the staff to cancel and re-schedule at his whim. Then, from another unit, a staff
member is called to pick up Jane and when she arrives, Jane then decides to go for a walk with
AB.
Cont.. Writer picked AB up from ________ Plaza at 4:30 pm and when he returned he was
happy to see Caleb was back. AB and Caleb left unit and returned 40 minutes later. AB spent the
evening (6pm onwards) with Caleb in his room. AB came out end enjoyed his dinner, sausage
rolls and a chocolate pudding. Writer only saw AB for 15 minutes from 6pm until the end of
writers shift at 11pm. Pete.
Monday
When writer arrived for his shift AB was in bed, AB got up at 2.30pm and told writer he was
going to have a shower and when he finished could he have his pocket money. AB was given his
pocket money at 4.00pm.
Comment: Again, this was a normal school/work day. Hes in bed until 2:30. No educational
programs or formal activities on offer and is then given his money to buy drugs.
AB is asking staff for money for having painted some parts of the unit a few days ago, saying
that staff have paid Caleb for painting. Writer remembers the day that both kids helped paint but

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

knows that they were not paid by staff on that day. AB became elevated saying that he was going
to bash Caleb if he didnt get paid. Writer went through the notes but couldnt find evidence that
Caleb got paid. AB called writer a dog and said that he was going to tax Calebs scooter and
sell it to get his five dollars and hurled more abuse at writer saying that Caleb would get bashed
if staff did not pay him. Writer said that he couldnt pay AB until he definitely found out that
Caleb got paid. AB left the unit at 4pm with Jane. Writer then spoke to Caleb about getting paid
and Caleb said that Ella had given him $5 helping to paint. Writer checked with Penny however
this information was found to be untrue. Stevie
Comment: Again AB here is behaving like a crude stand-over man, threatening violence if he
doesnt get his way. Although I am not a psychologist or similar, his threats appear to be
illustrative of his unstable and inconsistent mind-frame when he is acting in this manner. Instead
of threatening to bash the staff member, which would have made more sense and would have
been been his usual modus operandi, he threatened to bash a fellow young person/resident,
Caleb, who had done nothing to make AB angry with regards to this issue. This appears to not
make any sense - even within the disorderly mind-set of AB. He was saying to the staff member:
if you dont give me $5, youll be responsible for a young person under your care being
hurt or bashed.
AB came into the kitchen while writer was preparing dinner and said he was not feeling well. He
then vomited into the kitchen sink, writer gave AB some liquid panadol and within twenty
minutes he was wanting dinner so far he has held dinner down7.50pm. AB was still up at
11.00pm when writer finished shift. Alain
Tuesday
Writer arrived at 8:30am to find AB in bed. AB was given a wake-up call at 11am but failed to
get up until his ICMS worker Callum arrived to take him for a haircut. AB left for a haircut and
returned an hour later. AB engaged staff with a chat before spending time with his co-client
Caleb who returned from DOXA at 3pm. AB was well behaved all day. Pete.
Comment: ABs ICMS worker (intensive Case Management]) worker, took AB for a haircut.
This is hardly an example of meaningful, intensive intervention with this young person to help
deal with his deep psychological problems, anger, violence and drug use.
Cont.
AB stayed at the unit and left at 4.40pm returned at 6.40pm and presented well. AB came home
to his dinner that he requested (Tacos). AB had plenty of dinner and then interacted well with
writer and Caleb throughout the night. Later in the night AB spent time in his room playing XBox with Caleb and remained in a great mood for the remainder of the night. Stevie
Wednesday
AB followed writer into room 3 and became agitated when he saw that Tys belongings had been
moved. He started to rant and rave making threats toward Ty. He stated that Ty owes him
$70 for a bong he had broken.

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

At 1:30pm Jane arrived at the unit and asked for AB, writer also noticed 3 boys waiting out in
the driveway. AB asked Jane who is with you and she said Bill, Jack and Tom. AB asked do
they even smoke? AB and Caleb then left with the others heading up _________ St. Caleb then
returned with something down his pants, he went straight down to his room then left 30secs later
with something concealed again.
Later writer entered ABs room which was unlocked with the door wide open to put his clean
clothes on his bed and noticed that on the floor in plain view was a desk lamp which was
turned on, under that was a takeaway container with soil in it in which a small plant had started
to grow, writer checked with co-worker and then the internet and confirmed that it was indeed a
cannabis plant.
Writer spoke to AB and told him that I had to take his tomato plant into the office. AB seemed
very concerned and asked for the plant back. Writer told him that we will have to talk about it
later and AB left with Callum to have his hair cut.
Writer spoke to AB about the plant he was growing in his room, eventually he agreed that writer
could throw it away. Writer destroyed the plant in front of him as AB admitted it was in fact a
Marijuana plant.
Thursday
AB up out of bed at 9.30am comes to office to say hi to all staff in a good space. Alain.
Cont. AB was up and hanging around with Caleb today. His brother visited the unit twice
today and smoked a cigarette with AB at the letter box. AB rode Calebs scooter, went to his YJ
appointment, went shopping for shoes for Caleb and was polite, well behaved and respectful
toward anyone that the writer witnessed him interact with today. Pete.
When Writer arrived AB was in his room and believed AB was playing his Xbox and When AB
came out he was in a grate space then not long after, AB and Caleb went down the street around
5:20pm then came back at 8pm and all clients where in a good space then went to their rooms at
11pm as they said good night to staff. Rudiger
Friday
When writer arrived on shift at 4.30pm, AB was in his room AB came out to say hi and we
talked for a few minutes. About 9.00pm AB came to the office door and asked staff to ring
Rocco and tell Rocco that AB was not impressed that Rocco had taken his last smoke (bong as
he is in rehab). Staff did not make that call. AB asked if writer could take him for a drive and we
headed out for a drive writer and AB came back to the unit at 10.40pm all in good spirits, nice
chat on the way. Alain

Saturday

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

AB got up a bit after 12 when three young people came to see him. He went out with them for a
while returning after about an hour.
AB hung around the unit most of the afternoon, popping out once or twice.
He spent some time sitting in the drive chatting with a girl for a while.
AB spent the evening in his room. Staff cooked a roast for dinner but AB wanted fish and chips.
When staff told him we could do that tomorrow instead and that dinner had already been cooked
he threw the food over the floor.
AB also got the sauce bottle and wrote staff a message on the floor regarding cleaning up the
mess. AB threw about 6 or 7 oranges against the wall too.
After he settled AB was polite and chatted with staff. He mentioned that his sister had told him
that his eyebrows were a bit bushy. He said he would like to have them waxed to thin them out a
bit.
AB watched a little TV in the lounge with staff before having a shower and settling. Jackson
Sunday
AB slept in this morning and got up at 12.30pm. AB had a shower and interacted well with staff.
RM , Jane and another young person arrived at the unit at 2.45pm and then AB asked for pocket
money. He also tried to get extra money for bus money. Writer said that he would go with AB to
put money on his myki card but AB decided to leave the unit instead at 3.10pm.Stevie
At 6.10 pm AB called for a pick up from the ________ Train Station. Writer went to pick him up
and found Freddy F (who lives a couple of houses down) to be with him. AB asked if it was ok if
writer gives him a lift too. Writer agreed as neither of them appeared substance affected and
were in great spirits. Writer chatted with AB and Freddy F about their day, they informed writer
they hung out in town and didnt get up to anything in particular. After dropping Freddy F at his
residence in _________ Street.
AB and writer went to the fish and chip shop to order dinner. There was to be a half hour wait, so
writer and AB went for a drive. AB happily spoke with writer about life and his future with AB
telling writer he would love to go to _________ to study building. Once back at unit AB, Caleb,
co worker Jackson and writer sat at the table together and had dinner. Afterwards AB and Caleb
hung out together in the unit. Ella
Comment: the day before, AB had thrown all his food on the floor, wrote with tomato sauce
on the floor and threw 6 oranges against the wall because he was aggrieved at what had been
cooked for him (a roast dinner), whereas he wanted fish and chips. It didnt say in the notes, but I
almost guarantee that he didnt clean up any of the mess he made. But then, the next day, he gets
his fish and chips as demanded and apparently, his terrible behaviour the day before, had
absolutely no consequence. Again this is not care; it is institutional neglect that is not
helping the young person to learn about proper behaviour and how to live in the real world.

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Almost all children in Resi care are taught everyday that threats, abuse, violent or damage will be
rewarded or, at the least, that there will no or little consequences for such behaviour.
Monday
Writer took AB to dentist. He did not have a healthcare card and was turned away. AB asked
writer if he could book him another appointment tomorrow which the writer did. Writer chatted
to AB about family and his relationship with his mother this afternoon. AB was respectful to
writer and thanked him for taking him to the dentist. AB left early afternoon and had not returned
at the time the writer left at 5pm. Fred
Continued
AB was in great space when writer arrived for shift at 1.30pm. AB asked writer for some fish
fingers. Soon after AB ate he and Caleb were out the door. Claudia
Continued
AB arrived home at 10.45pm and shortly after his arrival and introduction to the new client, he
said to Mitchell/ Claudia that he was going to smash him, because he knows that the new
kid called Elliot had raped a 5 year old kid. Mitchell.
Tuesday
The writer noticed Graffiti on ABs door at 7.30am. I dont remember this being there last night
before sleepover. At 12.30 I cancelled ABs dental appointment as he said he didnt want to
go. Mitchell. 12.30pm.
ContABs brother came for a visit and then it was time for Callum to roll up and take him for
his hair appointment to get blonde tips, while he was away his sister came with two girls to see
him. AB was out so staff took the opportunity to give his room a good old fashioned shake down,
especially after finding a terrible attempt at a hydroponic setup last week. ABs room contained a
bong and a shank (see IR) Pete.
ContAB and Caleb met writer in the front yard when I arrived and greeted me cheerfully,
Freddy F was with them, both clients seemed to be in a good space joking with writer. Shortly
after AB said he was hungry and asked for dinner but as he had at least 12 fish-fingers freshly
cooked sitting on a plate writer said he would have to wait one hour for dinner. AB claims that
he is living below the poverty line and that it is inhumane not to have any chips in the unit.
AB enjoyed writers cooking eating a large serve of spaghetti, the only criticism he had was that
it had carrots in it. During dinner at the table AB spoke to staff about his cooking skills saying
that he would like to cook for staff and clients soon and that he would he would be willing to
participate in a master chef style cook off if staff can arrange it. After dinner AB and Caleb
returned to ABs room. Later, AB came into the lounge and started asking writer about Elliot, he
asked why he had to live with a paedophile and asked if we at the agency knows he is a
paedophile. Writer refused to humour AB with a response, instead trying to distract him with
what was on Television. AB repeated this a few times to co-worker later as well. Pete

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Continued
AB was not at the unit when writer arrived for shift as he was having his hair tipped at the
hairdressers. AB returned to the unit in great space, soon after he left with Caleb and his brother
Tom. AB is keen to start engaging with staff when cooking meals to learn some knew skills for
when he leaves residential care Claudia
ContAB appeared at the door close at 11pm. Elliot asked writer to open door, both clients
seemed to be up to something. Once the door was open Elliot kept asking writer to come out but
writer did not feel comfortable and feared he was being lured outside. Suddenly Elliot took
off running and AB pushed past writer chasing him. Writer followed them to the end of the
driveway but Elliot was pretty far ahead as they turned from _________ St into ______ St
towards _____ St. AB returned several minutes later badly out of breath, writer asked what
happened. AB responded if I tell you will you put it in the notes? writer said yes and AB
walked away into his room. AB left again a few minutes later.
Cont. AB left the unit at 11:15pm and returned at 12:37am presenting as being substance
affected, AB was in a very heightened state and displayed hostility toward writer. Later, writer
entered the floor as AB was trying to kick in Elliots door, and he was screaming threats to
Elliot who he thought was in the room. This went on for some time. During the evening AB
squirted dishwashing liquid all over the floors around Elliots door and ran around the unit
screaming and slamming doors, banging on the office door, playing loud music and yelling out
profanities. AB was last heard at close to 6am. Pete
Comment: Sounds like he had taken ice or amphetamines judging by his behaviours. This was a
Tuesday night he was up until 6am. A normal school/work day the following day. Again, an
illustration of Resi that night containing almost the full mix of all the negative behaviours as
discussed in the body of my main report: client-client conflict, drug abuse, client-staff abuse,
staff feeling scared (re being lured outside), bad body clock/up all hours/chaotic sleep patterns,
no school attendance.
Wednesday
At 10:20am writer received a Phone call from Callum, ready to pick AB up at 11am. Callum
came over and took AB to the psychologist for an assessment. In the afternoon staff took AB
downtown to see a mate and then he was dropped off close to KMART at 2pm. At 4pm AB
called for pick up and staff returned him to the unit. Pete.
Cont AB and Caleb asked for a lift to ________ railway station 4.45pm and were picked up at
6.00pm and came back to the unit had dinner and retired to ABs room 7.30pm.
Both AB and Caleb where in and out of the unit till 10.00pm just out the front till it got too cold,
then came in and where in AB room playing xbox till close. Writer heard Caleb say he was going
to bed about 2.00am. Alain
Thursday

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

AB wake up call for cognitive assessment at 9.45am for meeting at 11.00am didnt get up asked
to be woken later. Alain
Cont
Writer picked AB up from his cognitive assessment at _________. AB seemed in a great mood
but said he was tired from the day. Callum informed writer that AB must come back tomorrow to
complete the assessment at 11am.Writer took him to his Y/J appointment at DHS to see Fred H
and then back to the unit. It was organised from management that if AB painted his door he
could receive full pocket money. AB painted his door and received his pocket money and then
interacted well with Caleb for the rest of the afternoon. Stevie
AB spent all of late afternoon and evening in the unit hanging out with co client Caleb. A couple
of times AB came to the office to ask staff to settle debates the two were having when one
thought the other was wrong on a subject, all in good fun. AB was excited over tonights meal,
having a double serve before kicking back in his bedroom again, spending the night talking to
girls on his phone. Staff asked a couple of for AB to come out of his room for team meeting
however this was met with a continual in a minute. Ella
Contd
Writer agrees with above. AB was up a lot during the night laughing and chatting to people on
his phone. Jackson
Friday
Jane arrived at the unit at 9.25am saying they were here to pick up AB. She said her mum was
out the front in the car. Writer woke AB who got ready and was out the door in about 5 minutes.
Writer reminded him of his two important appointments today and he said he would make his
appointments.
Writer called AB to remind him of his appointment at 10.45am. AB answered and said he would
definitely be there.
AB phoned for a pick up after his appointment and came back to the unit. He said his
appointment went well and that he could start school at DOXA.
Writer reminded AB about his appointment at the solicitors but he said he would catch up with
them before court and asked writer to cancel the appointment. Jackson
ContAB and Caleb were in and out of the unit several times but seemed to be in good spaces
joking with staff when they did socialize but they mainly remained in their rooms while at the
unit, Pete
Saturday
Writer was on shift at 7.30am checked clients at 9.00am AB listening to music in his room with
Caleb. Alain

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

AB was just hanging in his room and going for walks with Caleb and has been in a good space,
Staff tried all day to get AB to do things with them like going for a drive, walk even the movies
but declined them all but said that he might go to the movies with Writer tomorrow. Rudiger
Continued
AB has spent most of the day in his room. AB has engaged with staff well today.. Claudia
Sunday
AB was up all night playing music, and having fun in his room with his 2 co-clients. AB asked
for some fruit at 7:45am, he then left with Staff to go over to AEs House. Pete.
Writer had not seen AB all day until he arrived back at the unit at 8pm with AE and he went to
his room with no expression on his face and did not speak to Writer. Rudiger
Cont
As Writer was finishing up the night, Writer heard a noise coming from ABs room at 11:30pm
as its next door to the sleep over room and did not sound right, so Writer went to the office door
from the sleep over room to see what was going on. AB and Caleb were fighting very violently
punching each other in the face for about five minutes. Writer tried to stop them by getting
in-between AB and Caleb and got hurt by one of them accidently. Writer stood back but was
talking to them to stop. As Caleb and AB stood apart, Writer went half way in-between them and
said to both of them to go to their rooms. AB stood around looking at Caleb and as Writer was
following Caleb AB went to his room and then Caleb went to his room. Writer said to Caleb to
stay in his room and try not to come out unless Writer was at his door. Caleb was happy with
that. Writer phone on call (Annamaria) and said what had happened and was notified to call DHS
after hours (Josefina) and gave Josefina the info on what had happened between AB and Caleb.
Josefina was concerned if there was someone doing a stand up and Writer said he will notify oncall about it. After DHS phone call, Writer rang on call (Annamaria) and said Josefina (DHS)
was wondering about a stand up and was told that it would be late for a stand up to come on.
Writer understood. AB at times came out of his room and walked by Caleb room saying I
wouldnt come out if I was you. Writer said to AB to leave Caleb alown and AB went back to
his room. At around 12:25am Writer was hearing a noise coming from the floor. Writer went to
the office door to see who it was and it was a girl. Writer said to the girl she had to leave and she
said she wanted to get a smoke off AB, then AB opened his door and let her in. Writer then rang
on-call to let her know and was toled try to get the girl out, if not, call the police. Rudiger
ContWriter arrived at the unit and was met by AB in the driveway who was with Delphine
and Freddy F. AB was talking extremely fast and a few times lost breath, writer commented on
how small his pupils were and he stated that it was from all the energy drinks he has had, writer
noticed his mouth was dry and that he was chewing non-stop but was not eating anything. These
behaviours can be associated with being on amphetamines. Writer waited in his car as I felt
uneasy to leave it in the driveway until staff came out and moved some other vehicles so I
could put it in the garage. Once inside the unit, AB was desperately seeking identification so he
could get a new bank card. Delphine followed him in and was asked to leave several times but

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she refused to do so. AB said that she had knocked on his window in the middle of the night
saying that she had no-where to stay so she stayed here. He was more speaking to Delphine and
didnt seem to be aware or possibly care that he said it in front of staff.
AB started demanding to come into the office after writer had opened the door to pass him a
phone call from Josefina. He put his foot in the door then tried to push past eventually slipping
under my arm and into the office, writer called out to staff who were talking in the other
room and they came just as AB went back out with his personal information folder which I
had been going through.
Staff told writer that while they were in the driveway talking, that Freddy F had lifted up his shirt
and she noticed that he had a package stuffed in his pants that contained drug bags and a
syringe.
AB eventually went to the Bank with Delphine and returned quickly with Delphine out if breath
extremely escalated yelling that he had just bashed his friend Fred D. He said he has had issues
with him for a few weeks and that they had just had a fight in the street outside of the ________
Bank, he tried to show writer a chip in one of his back teeth but writer found it hard to see. Again
he let Delphine into the unit and writer asked many times for her to leave. Pete
Cont
The writer met AB when coming onto shift as he was up and out of his room. AB seemed very
fidgety and on closer inspection his eyes were wide and fixated. During the course of the
morning I escorted AB to court where his appearance was adjourned until 12 August -------------.
During this period he was openly aggressive to a fellow attendee and was asked on a number
of occasions to be quiet. Pauley.
ContAB left the court with friends and returned to the unit at 9:35pm substance affected. He
was very jittery, very pale and his eyes were extremely dilated, he was twitchy and talkative.
He seemed to be trying to distract workers possibly to try and sneak Delphine in again, a female
voice was heard outside the unit and writer believes it to be Delphine. AB was very concerned
again that staff would IR him and he seems to be displaying some paranoia stating that he thinks
he is going to be moved from _________ St Unit soon. Writer is worried about ABs health as he
looks so ill. Pete
Tuesday
Staff check on AB in the morning AB got up about 1pm Staff made him bacon and eggs. At 2.25
pm, Delphine was caught in the unit, staff asks her to leave. Pete explained to Delphine why she
cannot be in the unit at any time. Delphine was also warning the day before that if she was to
come inside again, she will be getting a Trespass notice. Annamaria
Cont... writer was in _________ when I received a call from Ella at the unit, AB had called her
for a pick up. I was only 2 blocks away at the time so I was able to pick him up straight away.
He got in the car in a highly elevated state, he started making threats toward Caleb because Ella
and Caleb didnt come to pick him up. I explained that we only have one vehicle and that I was
away from the unit already in the car. He refused to believe that the unit had been without the

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silver car for almost one week. He escalated toward me and I was forced to pull over after he
whacked me in the shoulder and threatened to jump me for the car after a few minutes of
sitting their being yelled at and threatened writer decided it was safe again to continue driving.
He eventually admitted that he was actually still angry at Caleb . On return to the unit AB bashed
on Calebs door threatening to bash him and calling him names. Then he turned to staff and
started accusing Ella of trying to trick him, he ended his rant by saying you cunts are lucky I
dont jump up and down on ya heads and went into his room. 5 minutes later he came back
out and quietly knocked on Calebs door asking him if he got the message and Caleb opened
the door and they seemed to make up. ABs behaviour has again displayed a high level of
aggression and being unpredictable. Pete
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Wednesday
Rocco was up early this morning as he is playing football in Melbourne which he is excited
about, he put his boots on straight away and went across the road to run some laps to warm up.
He took his meds and was given $15 for the day before writer and he went outside to have a
kick, shortly afterward he was picked up by the bus. Pete
Rocco returned to the unit at 4:40. Rocco said he had an awesome day playing footy. Rocco has
interacted well with staff and co clients this evening.
At 6:40pm writer took Rocco and co client Ty to ________ plaza. Rocco refused to come back
with writer and said he would walk home with co client Ty. Writer has informed on call.
Writer calls Rocco at 7.10pm. Phone is turned off.
Rocco returns home at10:05pm. Rudiger from _______ st called and said Rocco and co client
were hanging out with a female client from _______ st. Paula
Thursday
Rocco woke at 9am this morning in great space. He has had pancakes for breakfast then left with
staff Marco for programs. Writer mistaken the day for Tuesday and Rocco s program didnt
begin till later in the day. Rocco had a laugh about this mistake Claudia
Cont.Rocco was suspected of smoking cannabis inside the unit this afternoon, he and AB
were spoken to by staff and they were told that staff will be conducting random room searches
because that behaviour will not be tolerated. Later Rocco admitted to being substance affected.
Staff told Rocco that they will not facilitate taking him to football training in that state. Rocco
reacted badly to this stating we are going to ruin his AFL career, staff responded by telling him
that he will ruin his own career if he is going to continue taking drugs. Rocco escalated
violently, kicking the unit vehicle and demanding to talk to Angie. Rocco did not eat much
for dinner and left the unit shortly after receiving a phone call from a female. Rocco is on a 24hr
car ban for damaging the vehicle when he kicked with his boots. Pete

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Friday 31/5/13
Rocco up at about 9.25am stating he does not want to go to tutoring unless he can play footy
there. Tutoring was contacted and they said they were short of teachers today, so Rocco was not
able to go anyway.
Rocco arranges to go to for a kick of the footy with Rosemarie earlier than their planned time
and Rosemarie picks him up at 9.55am.
Rosemarie returns to get some jeans and runners for Rocco at 10.50pm as he had decided to
stay in town playing footy with some kids that had rocked up. Jackson
Comment: Staff take him jeans and runners at almost 11pm which is meant to be when they are
all inside the unit and staff starting sleepover! This is probably an example of the staff doing
something to stop a child getting angry or exploding and to make their shift better.
----------------Rocco seemed frustrated at the unit and asked to go to his Mums place. He told staff that he has
DHS approval to do so. Writer told Rocco that he would need to call on-call but Rocco
demanded we call his mum instead, staff did call his mum who asked to speak to Rocco and told
him that he could not come tonight and that he knows that. Rocco was crying after the call and
staff consoled him briefly.
At approximately 9:45pm writer discovered that the rear door was again unlocked but pushed
closed to make it look locked, writer also noticed that all clients were being very careful while
going in and out of Rocco s room, writer got co-worker and opened Rocco s door catching
them unaware, AB had a pair of scissors in a bowl and writer suspects that they were about to
chop up some cannabis, writer could not gain full entry to the room but believed there to be an
extra person in their room. Writer stated they should leave and told everyone that I will have to
call on-call. After the call, writer asked the clients to remove the drugs from the unit, they stated
that they would go somewhere else to smoke it, showing both staff members a small bag of
cannabis and a glass bong, they also had another short male with them, possibly the same one
that they snuck in the other day. Writer told Caleb that he could not leave the unit because of his
8-8 curfew but Rocco and Ty distracted staff at the door while Caleb snuck out. Staff have made
sure the back door is again locked but fear the clients have a special trick to open it. Pete
Cont Staff heard the clients come running back from their short trip; they stood on crates at
the side fence and started hurling abuse at the security guard over at the public toilets. Ty,
Rocco and AB were the main offenders; it is unsure whether Caleb was directly involved. The
abuse was threatening and went on for some minutes. Eventually the police arrived at the unit
saying the clients had actually run at the guard with sticks so he called the police. The Police
were very familiar with all our clients and asked which ones are currently residing at this unit.
The police were in good spirits and gave the impression that they are not going to spend much
time looking for the boys who were hiding over in the park. Pete
CONT At 12.15am writer went into the unit to unlock Ty door so was able to go to bed as
writer was coming back into the office Rocco,Ty and AB grabbed writer by the arms. Then

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Rocco said lets take his keys, which writer had in his hand so writer could enter the office. After
about ten minutes of wrestling Rocco went to his room and came back with a fish scaler and
attempted to open writers hand but only made writers hand bleed a small amount. Writer
explained that if they continue writer would have to report this to police. After another two
minutes Rocco and AB stopped and went back into the unit saying you do know we were only
mucking around writer said yes. Ty was still standing next to me and wouldnt allow me to enter
the office. When writer asked Ty to move Ty said to writer what you gunna do white boy, and
then repeated the same racist comment. When writer was able to get into the office Ty kept
holding the door handle. Ty then let the door go and then ran into the unit yelling out to Rocco
telling Rocco that writer had called him a black boy, which never happened. Writer was
incensed that Ty would say such a thing and went back into the unit, as writer was coming down
the hall way writer could hear Rocco saying to Ty that he should give him a beating for lying
about writer. Writer them got Rocco to settle and was talking to Ty trying to explain the
ramifications off his actions, Rocco went back to his room and Ty looked very sheepish. I think
he realised what could have happened in the situation. Alain
Cont unit closed down at 12.00am all clients in unit. Alain
Comment: Obviously the staff member was by himself with these three children including at
least one bordering on the sociopathic (AB). This is an example of irresponsible duty of care
and an inappropriate OH&S framework on the part of the CSO. At one stage the staff member
had to be in a physical tussle with the kids for ten minutes, including being cut with a fish scaler,
to stop the boys grabbing the unit keys,.
If one of the boys was coming down off amphetamines or ice, the fish scaler might have ended
up in the staff members eye or used to cut his hand very deeply. The evening was almost
continual conflict, and a power play between the kids and the staff member. Of course with
three kids against one staff member, the children are going to be the winners
Saturday
Writer called Shane (on-call) and informed him of what went on last night. CLIENTS Rocco
AND Ty ARE ON A 24 HOUR CAR BAN DUE TO ASULTING STAFF AND TRYING TO
GET INTO the OFFICE.
Rocco said co client Caleb was sick on his bedroom floor. Rocco asked if staff can double
check that his bedroom door is locked if he goes out. Paula
This evening writer was watching TV with Ty when Rocco came out of his room and asked
Caleb to come here for a minute. The door shut and within minutes writer could smell what she
believed to be marijuana. Writer immediately went into the office to tell co-worker. Writer and
co-worker decided to creep around the back of the unit to peer into Roccos room through his
curtains. Both writer and co-worker (Paula) observed Rocco and Caleb smoking a bong by
looking through the bottom of the curtains that were not pulled shut properly. Once back inside
staff heard a bang on the office door. It was Ty who stated to staff he had just been punched
with hard force by Rocco . He was visibly shaken and scared. Writer called the police
regarding the assault and drug use. In the time between calling the police and their arrival Caleb
and Rocco were making threats towards Ty, calling him a snitch. Two female police officers,
Smith and Jones arrived at the unit and interviewed Ty who decided to charge Rocco with

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

assault. Police conducted a room search after interviewing Rocco regarding marijuana use and
confiscated one bong. While police were at unit as well as after, Rocco was very calm. Rocco
mentioned he wanted to play footy tomorrow. Writer called North ________ Junior Football
president to get permission. Stevie went to Kmart to get some footy shorts for him. Ella
Comment: While Rocco at least being involved in a community activity such as footy is
positive, the above excerpt is nonetheless an example of the chaos and dysfunction in so many
Resi units: Marijuana use, a violent assault and police attendance one day; footy training the
next. It is all so abnormal and the unit daily life is full of chaos, inconsistency, threats, assaults,
fear, conniving, lies, deceit and drug use, broken up by the occasional apology for misbehaviour,
a little chat with staff or footy training.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Wednesday
Ty was woken up and checked on early this morning but did not get up, he remains in bed at
12:15pm. Pete
Cont Ty spends time with staff today and helps cook some meals for the unit. Ty seems to be
getting along with all young people, with nil issues. Ty and staff head out and clean the unit car.
Ty has been in a great space all day; he has interacted well with staff and co clients. Ty informed
staff the x box has gone missing. Staff removed the TV from the games room. Paula
Writer takes Ty and co client to ______ plaza. Ty refused to come back with writer and said he
would walk home with co client Rocco. On call has been notified. Ty returns with co client
Rocco at 10:05pm. Paula
Thursday
Ty woke in good space this morning and is off to __________ with staff Shavonne, for access
with his grandmother.. Claudia
Cont- Ty was in good spirits on way over to nans, Ty assured writer that the bruise on his leg
was from mucking around with staff and that he had kicked staff member first and this happened
in play. Ty wasnt real happy when Nan told him he wasnt staying till Sunday, however he was
settled when writer left. Ty is to be picked up on Friday at 5pm from Nans house. Shavonne

Friday
Phone call to Alvina re:- Tys pickup time today and she confirmed it to be 5pm. Ella has been
organized to do the transport. Jackson

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Ty arrived home and was in a good space. While driving to Maccas, Ty was being very silly and
rude. Ty was swearing at passing cars and saying he was going to piss on writers car if his
McChicken was spicy. Paula
Cont..
Ty was in a heightened mood full of confidence we he returned to the unit tonight. He bounced
around talking with the same accent and style as a former client. He interacted well with other
clients and eventually settling down and interacted with staff well, Ty was very helpful cleaning
up a large mess of 2 min noodles that another client had smashed around the front of the
unit. Ty asked for his pocket money later with AB by his side, writer got the impression that AB
wanted it more than Ty and the request was denied as he was not in the unit last night. Pete
Comment: it is very common that one client forces another to give them their pocket money of
part of it (the equivalent of a school bully stealing lunch or lunch money). This is usually for
drugs.
Cont Tonight Ty has misbehaved badly. He has abused staff and been the main instigator in
abusing the security guard. Toward the end of shift Ty planted himself in the door way
threatening to slap writers hat off, he has been menacing and seems to be substance affected.
Tys behavior has been very disappointing and can only be blamed on trying to fit in and be
accepted by the other boys. Pete
Saturday
Ty asked staff for all his savings, writer said no. Writer told Ty if he wants to spend his savings
then staff will take him shopping. Ty got his five dollars pocket money and gave it to co client
AB . Paula
Sunday
This morning Ty arose happy to know that AB had not returned to unit, Rocco was at footy and
Caleb was still asleep. Ty chatted to writer over breakfast, expressing his interest in getting an
IVO against Rocco. Ty was still shaken over the assault the night before. Once showered, Ty and
writer went for a drive before writer took him to a friends place at ______Street. Writer went in
and met Sally, an older woman, who was happy to see Ty and let him hang out for a while. Ella
When he arrived home, Ty was extremely nervous and stressed due to the constant bulling from
co clients. When Ty arrived home co clients AB and Rocco started to verbally abuse Ty.
7:10pm Ty tells staff he is running away.
Sunday
On handover Paula told the writer that AB is bullying Ty really badly and AB threw Tys dinner
in the bin. Ty had already left the unit and Paula had said Ty stated he was going to the train
station to go to ___________ and get picked up from there.

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Angie called and spoke to Rocco and AB about the bullying of Ty . They told Angie they wont
do it anymore. AB did state that snitches get stitches.
The writer called DHS after hours. They asked the writer to call his Nan. She didnt answer the
mobile. Paula suggested to call the ___________ Police as Ty stated he was going there on the
train. Spoke to Sgt Alain White who stated they had spoken to Ty at the station earlier and he
had called his Nan Alvina who was coming to pick him up.
Ty told the police that he resided in Residential Care and was bullied. The writer tried calling
Alvina twice at 10.55pm but no answered and then left a message. At 11.10pm Ty called the unit
reverse charge and stated they had only just arrived at Nans house as Alvina got lost on the way
back. The writer told Ty that they will call him tomorrow around lunch time after talking to
DHS. AB heard this conversation through the door and started yelling out threats your fucking
dead Ty . Tammy then spoke to DHS after hours to let them know Ty is safe. Tammy
Comment: This little snippet, almost says it all: This child in Resi is being so badly bullied
including forced to hand over his pocket money and being punched and assaulted, that he runs
away from Resi to be safe with his Nan part of the dysfunctional extended family he was
removed from in the first place! Without wanting to be overly repetitious this is not care, it is
institutionalised state neglect of this childs basic right to be living in a safe, peaceful
environment while being legally under the guardianship of the State. As I also stated in my
report, although I am not a lawyer, I imagine this child and thousands like him would have a
legitimate case to sue the State for gross negligence and for emotional and physical harm
received while under so called State protection and care. This young man (only 13 at the time),
was also not attending school regularly (two days per week for an hour in a special program in
which he was involved in a vegetable garden project). Again, this is the State/DHS, via the CSO,
treating this child with contempt. As mentioned in my report, as a contrast of spending priorities,
a rural State MPs can spend $50,000 to study public libraries in Paris, but we provide
essentially no education to a 14-yr-old child under our legal guardianship. Lets say there are
only ten MPs study trips each year. This would add up to around $500,000. Let the State provide
a maximum of $5,000 towards each of these trips and any other cost can be topped up by the MP
out of their own money. The revised cost for 10 MPs would be $50,000. So the $450,000 saved
could go towards Resi care educational programs. If there are 20 such MP study trips each
year, the saving would be $800,000. This adds up to a reasonable amount of money that would
be much better spent on providing healing programs or education for traumatised children in our
collective care than for study trips for well paid MPs that, for the most part, serve no useful
purpose for our community.
Thursday
When writer came on shift Ty was being transported back to ________ from __________ by
Tammy . Once they got back to _________, writer was asked to take Ty to his solicitors. Ty was
very agitated and vocal in regards to him returning to the unit. Ty told writer there was no
chance in hell he was returning to the unit as he does not feel safe. Ty threatened to steal car
from writer and pull on hand break if the meeting with solicitor ended badly. Writer informed Ty
this was not a brilliant idea as he would land himself in serious trouble with the law and writer
did not have a death wish. Once at the solicitors we had to wait as he was running late. This
aggravated Ty more as well as gave him time to think of what demand he wanted. One of these

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ideas was to hold the solicitor and writer hostage. Ty also spoke of killing himself as he
would rather be dead than alive.
Writer told Ty this too was not a good option as Alvina as well as writer themselves would miss
him plus the best years of his life are ahead of him even though he cant foresee this now. Tys
solicitor asked Ty directly what he wanted. Ty said he wanted to go back to Alvinas as he would
not return to the unit. The solicitor got Alvinas phone number from Ty and called her to see if
she would be willing to take him back, she said yes. Writer assumes Solicitor also called DHS as
they called to inform writer that it was ok. Ty was ecstatic with the news. Writer drove Ty
straight to Alvinas and set him up there for the next few days. Ella
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Sunday
Overnight on 1st June into the 2nd AB absconded and did not return to the unit until 2.45pm on
Sunday 2nd June, stating that he had stayed at a friends house.
On ABs return he was in a great head space, happily chatting to staff and riding his scooter. An
hour later writer and co worker Paula witnessed an un known male leave the unit, coming from
AB room. At 5.55pm Writer received a personal call for AB. Writer asked if they could call back
in 5 minutes as writer needed to use the phone for the time. The unknown male said thats ok
my and my sister are around the corner and will be at the unit in few minutes. AB then came to
the office and tried distracting writer while his friends snuck in. AB believes he was successful
however writer saw a young female and young male enter through the side of house. Writer went
and warned AB his friends had to go Ella
AB has been verably abusive towards staff and co client Ty all afternoon. AB had four of
his mates coming in and out of the unit, when AB was told his friends had to leave he
became loud and highly verbally abusive. Police were called due to ABs friends being in
the unit. When police arrived, ABs friends ran away. AB has been in a very controlling
mood tonight. AB demanded Claudia go and get him milo. Claudia asked AB to wait as she
was cutting up dinner, AB picked up the roast and put it in the bin. AB bullied co
client Ty so much that Ty ran away.
Sunday 2/6/13
AT 8.25pm Angie calls to speak to AB and Rocco on speaker phone re the bullying to Ty. AB
listened to what Angie said and AB was calling Ty a snitch and he was the one who dobbed to
staff about them smoking dope. The writer said to AB that he isnt allowed to smoke dope and if
he didnt do it Ty wouldnt snitch. Angie told both AB and Rocco that Ty may not have been the
one to snitch so not to pick on him and blame him. AB then tells Angie that snitches get
stitches.
At the end of the call AB promised Angie he will stop bullying Ty. AB spent time in Roccos
room. At 10pm AB leaves on foot to go to a friends to pick up a keyboard. He returns at

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10.30pm with the keyboard and plugs it in to play for staff. Once the standup arrives at 10.30pm
AB thought Ty had already returned and started making threats at Tys bedroom door. AB then
overheard the writer on the phone to Ty from under the office door and he yelled out your dead
cunt. At shutdown when the standup staff arrived AB assumed Ty was back and in his room.
AB started yelling abuse to Tys door come out you fucking rat Im goin to kill you. AB
then realizes Ty isnt back. AB asked why there is a stand-up on. The writer said its due to you
bringing in all your friends and the drug use. AB replies yeah true. AB then tries to get staff to
give him a plastic bag. The writer asked him what for and he replied to hang myself then
laughed. The writer pretended there wasnt any and Tammy hid them in the bedroom. He was
persistent with asking for the next 10 minutes for a plastic bag. Staff had concerns the clients
wanted to Chrome. AB said he wanted to do a magic trick with it. Tammy
AB was smoking in the unit. After Rocco went to sleep at approx 12.30am, AB and Caleb moved
into Caleb s room. Karina (Standup) said they were smoking cigarettes in Calebs room. AB
settled at 2.30am. Tammy
Monday
AB is up and about at midday today. AB proudly walked out his brother Tom who had been
snuck into the unit during the night and slept on ABs floor. The writer mentions to AB that some
new rules will be looked at for the unit due to the recent behaviours of all clients within the unit.
This didnt go down well and AB stated Im gonna make your life hell and youre lucky the
office door is closed. The writer disengaged and AB left with Rosemarie. AB has been in an
aggressive and combative mood all day. ________ Police were called regarding the electric
piano AB had in his room. Police took this to investigate wherever it was stolen. This also
didnt go down well with AB. Marco
Cont AB returned from YSAS with Rosemarie and went straight across the road where Rocco
was kicking the ball with Pauley, he seemed disgruntled and told writer that he wanted to talk to
him about these rules that fuck head Marco has made up, while he was over there he was
seen to be kicking the ball and having fun playing footy. On return to the unit he was again
aggressive toward Marco, at one stage he demanded the phone, Marco spoke to him explaining
how his attitude was not very good toward staff at the moment. AB quickly opened the door and
pushed his way into the unit grabbing the unit phone, writer told him that we would just unplug
it from the wall if he didnt return it straight away, but he did not give the phone back. He
walked across the road and writer followed and witnessed AB throw the phone about 60m.
Soon after he returned to the unit saying that it wasnt broken and that he still wanted to make a
call, writer told him no and showed him that the phone had been replaced with a chord phone
that the clients can not use. ABs brother was hanging around the unit, he appears to be homeless
and some food was given to him and he was reminded that he could not come into the unit and
that he would have to find somewhere else to sleep tonight as _________ St are having stand-up
shifts. He was polite and thankful. Jane (ABs sister) also spent a lot of time at the unit today and
had to be asked a number of times to leave the unit, writer explained that we will be getting a
trespass notice against her and that staff may be required to call the police if she continues to
enter the unit. AB was seen eating and enjoying the shop brand noodles that caused him to have
a violent escalation only three nights ago. Caleb spent a lot of time in AB room and they seem to
be getting along very well. Pete
Contd

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

AB has been in a good spot this evening. He has been polite with staff and spent most of his time
in his room with Caleb playing x-box.
AB spent some time with his Brother Tom outside who is supposedly homeless.
At 10.25pm AB went out the front from his room and another young person (Fred D) was with
him. He must have come into the unit earlier without staff seeing. Fred D left on a scooter.
AB hung around the unit until shutdown. Jackson
At 1.40am AB had his brother in his room but denied it when asked by Pierre. AB was informed
that the police will be called so he came out and asked that the police not be called as Tom was
leaving.
Pierre chatted with Tom about seeking help for his accommodation. Both clients were polite and
calm.
At 2am AB and Caleb leave the unit. Pierre tried to call both boys about 20 minutes later but
could get no answer.
AB phoned for a pick up at 3.25am but was informed he could not be picked up due to the keys
being in sleepover room with staff asleep.
Both AB and Caleb returned to the unit at 4am.
Tuesday
Writer gave AB a wake up call as he requested at 11am but he went back to sleep after
responding to it.
AB got up at about 11.40am when Tom arrived to see him.
AB told Rocco that if Rocco ignores him again then he would bash him.
AB spends time hanging out at the unit and outside with Tom and Jane when she arrives.
AB and Caleb asked for a Myki. Writer reminded AB that he had had one bought for him the
other day. He stated that he had lost it. Writer told both boys that staff would purchase one each
out of Petty Cash and made it clear that if they lost it this time they would not have another
purchased for them. Both boys agree to this. Jackson
ContAB was in and out of the unit all day again, Tom was also lurking around the unit and
was polite to staff, staff asked Tom where he was staying and he told us that he would again be
sleeping in the tent and that he had organized some emergency accommodation with a ________
group. Jane was also hanging around the unit, she was polite to staff and asked for a pick up
about 6pm. Staff searched ABs room about 6:45pm, staff easily located a very smelly bong. All

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clients have spent time in ABs room over the last few days and all are suspected of being
substance affected. Pete
Cont
AB has been in and out a bit throughout the night, he did not eat dinner and spent most of his
time interacting with his brother Tom and sister Jane .He also had a friend (Fred D) that was at
the unit for a fair bit of the night and also snuck into the unit at one occasion. Once Tom and
Jane left the unit AB interacted with Caleb. AB and Caleb left the unit at 10.30pm telling writer
that he was going to get some bumpers. AB called for a pick up just before shutdown from _______. Stevie
Wed.
AB spent time with Caleb in his room talking and playing computer games. AB informed writer
that Ty owed him $75 for a bong he broke and thinks that he will be scared to come back to the
unit because he will get bashed if he does not pay the money back. AB wanted his shoes from
the laundry at 6am. Writer got shoes but they had not been cleaned, AB put them in the washing
machine and asked that they be put in the dryer when washed. Writer said he would but it when
he did the dryer banged around a lot so the shoes were taken out. Jackson
Cont AB presented as being substance affected again tonight before dinner, again he
managed to sneak Braydon F into the unit, this time AB spent time walking around the unit with
his hood pulled down so you could not see his face, going out of his way to make sure that staff
knew it was him, then he went outside and swapped clothes with Braydon F and Braydon F
walked into the unit straight into ABs room, a few minutes later AB walked in wearing Braydon
Fs jacket, writer did not fall for this and went straight to ABs room where Braydon F was
hiding under the desk, writer informed them that the police will be called if he doesnt leave,
Braydon F agreed and swapped clothes back with AB.
AB had noodles and some roast beef and veg for dinner then went to his room to play
Xbox. Later at approx. 10:10 Tom (brother) came to the unit requesting that writer wake AB up,
writer knocked on the door and went in to tell AB that his brother was here, by the time AB got
up Tom was gone, AB remained up calling writer a liar and demanded food, when writer
told him that there was no milk left AB escalated quickly getting in writers personal space
threatening to hurt and kill him if he didnt go get some milk, writer explained that it was too
late and that he would have to eat something else, this was not acceptable to AB who again
threatened to hurt writer, writer withdrew to the office, he then came to the office and demanded
food, he stated the writer plays God with food, writer said that was not true and he angrily said
then why didnt you go get milk earlier when you knew we ran out because you knew I would
want it, writer explained that he did not have time, Writer offered him a number of things and he
settled for dino bites. ABs behaviour has again not be acceptable. Pete
Thursday
Writer arrived for shift, AB was in his room. Whilst writer was cooking dinner AB approached
writer and asked what she was doing. AB appeared to be substance affected being very hypo
and having large pupils. AB and Caleb then left the unit. A phone call was made to the regarding
another client, AB demanded to know who it was, writer told AB the phone call did not concern

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him, AB became very abusive demanding to know who was on the phone. AB then started to
call writer a lying bitch and told her that nobody was on the phone she was just pretending.
Writer and staff Ella did a room search to find many used bags which contained a glassie looking
substance. (ice ) Police were called and attend the unit. They found around five little used bags.
AB and Caleb arrived back at the unit whilst the police were onsite. AB was asked to empty his
pockets out onto the bench. AB was reluctant to empty the right side of his hoody pocket but
continued to empty other pockets. When police left AB became abusive towards writer calling
her a mole, bitch and copper snitch. Writer shut staff door and disengaged.. Claudia
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Saturday
AB was out on the writers arrival at 6pm. At 7.20pm AB called for a pickup from ___________
at the bus stop in the main street. The writer and Marco left to get him. AB called again in 8 mins
and asked where we were. Nearly there and told AB when he got in the car that it takes longer
then 8 mins to get to ___________ . AB seemed escalated and really anxious about having to get
to ___________ by 8pm to meet his mates at the bus stop. I told AB that the writer felt really
uncomfortable dropping him at ___________ at night on a Saturday night. AB started to make
threats and demanded to be taken home to eat noodles then out to ________. He continued to
stress to the writer that he had to be there at 8pm, repeatedly saying it. The writer said they were
calling Oncall to find out about his transports before they transport him. AB wanted to speak to
Bob T On call also. I had a quick conversation with Bob on the phone before AB got to the
office door demanding to speak to Bob. Both the writer and Bob told AB that we were here to
keep him safe and transporting him wasnt a good idea. AB continued to say that he gets
transported wherever he likes whenever he likes. The writer along with Bob decided that due
to not knowing his curfew and it was before 8pm that they will drop him at the train station so he
can catch a bus to ________. AB was dropped at 7.50pm and was very thankful. (Pretty obvious
this was a drug pick up). AB called for a pick up from the train station at 9.30pm. AB returned
and his behaviours were erratic. eg, he carried his backpack on his back for half an hour around
the unit, he was back and forth to the office for the phone, he asked for a pen to do his homework
and wanted to talk to staff about Octagons and shapes. His pupils were large and he seems to
have lots of energy, the writer noticed his speech was very fast. AB hasnt had anything to eat
while he has been at the unit at shut down writer went to J.S room to say goodbye and noticed
that his window was wide open, writer asked J.S why his window was open it is freezing outside
and J.S replied its really hot in here. Tammy
Cont writer on at 11:00 pm for sleep over. Just before shut down, AB was reminded of
shutdown and asked if he wanted any snacks etc. After shutdown, AB was heard in the kitchen
making noodles etc a few times during the night, but did not bang on staff door or similar and
was then in his room all night. Al
Sunday
AB got up at 1400hrs and came to the office to ask the writer if she had seen a T-shirt of his, the
writer told him that she hadnt and AB then demanded that the writer let him into Janes room to
search for it. The writer told him that he could not go into her room while she was out of the unit.

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AB told the writer that she was his fuckin sister and she takes his clothes all the time. The writer
entered Janes room and told AB to wait in the hall. AB waited about 5 seconds and then
followed the writer in and proceeded to search Janes room for his T-shirt. After not finding the
T-shirt in Janes room AB took two small items off her bedside cabinet and a black cap with
yellow writing on it. AB then demanded that the writer open Pennys room, the writer told AB
that her room will not be opened as Penny was not in the unit. AB then told the writer if the door
was not open he will do some damage to get in, the writer told him that if he does any damage
then the police will be called. AB preceded to try and kick Pennys door in but found it would
not open, he then went outside, shortly after AB came to the writer and said that he had told the
writer the T-shirt was in Pennys room as he had found it folded on her bed. The writer asked AB
how he had gotten into her room and he replied that he had said he was going to do some
damage. The writer went into Pennys room after finding the door open and found that the
window had a big crack in it and that it had been opened. The writer contacted on-call (Bob),
OBriens windows and ________ Police. Constables F. Smith and P. Jones arrived at the unit at
1510hrs and charged AB with wilful damage. After the police had left AB requested a drop off
and worker Jess dropped him off somewhere in ____________ at about 1607 and at 1620 before
Jess even returned to the unit the writer received a call from AB wanting to be picked up again.
Comment: how ridiculous..! This violent young man, carries out property damage, is charged
by the police but is then simply driven around and picked up again whenever he wants like the
staff acting as his personal chauffeurs! There is little consequence for any of his actions. Being
charged by the police for a regular person would be a serious thing. Not for these kids. He
would have bragged about it to others plus knowing that nothing would come of the charge due
to his age and cos he is a resi kid. They play the system and just think it is all a big joke.
At about 1810 AB started to escalate over wanting to get a phone with the money that Callum
had left for staff to get for him. Staff tried to explain to AB that staff are not allowed to connect
phones for clients that it has to be either DHS, ICMS or Angie. AB would not believe this and
worker Annafrid called Bob who confirmed that under no circumstances are staff to use their ID
to get phones for clients. AB then took the unit TV from the lounge stating that he was going to
sell it, he also said that he would burn down the unit. Staff tried talking AB down without much
success. Jane returned to the unit at 1845 and AB appeared to be much calmer. AB then came to
staff saying that he could get his phone and connect it himself with his medicare number. After
contact with Bob who approved for AB to connect it in his name Annafrid took him to Coles to
purchase a mobile phone but soon returned with Coles having informed AB that he needed ID to
buy one. AB remained in a better space. Roslyn
Cont;
AB had asked to go for a drive so writer said yes after she had picked up co-client. On return to
the unit AB then said he wanted to drop a controller back to a friends house. Writer replied she
was happy to take him for a drive but was not going to stop at someones house while he got out
and then got back in the car. AB argued with writer about why he couldnt drop something at a
friends. Writer stated her reasons for not doing so and AB eventually calmed down. Writer took
AB and Jane for a drive at 8.40pm and returned at 9.45pm. AB and Jane went to their rooms, at
10.15pm. Katja (co-client) came to the office very heightened stating AB had threatened that if
she didnt give him her phone in 45 minutes that he was going to send Jane into to bash her. Staff
tried to calm and reassure her and staff walked her back to her room. Roslyn (staff ) went into
Katjas room with her while AB and Jane continued to harass her through the door.

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Jane had also grabbed a nearly empty can of Deodorant from Katjas room when she left it with
the door open. AB had lit it against JHs door and again out in the kitchen area. Writer grabbed
the spray off AB and took it to the office. Staff phoned on call at 22.20hrs Marco had not wanted
to call the police at this stage, staff phoned on call again at 22.25hrs The police were called at
22.27. AB and Jane continued to harass Katja. They lit sparklers and were waving them into her
room under the door. When they did this again Katja felt trapped and threw herself at the
window and broke it. The ambulance were phoned at 22.28 as Katja would not let staff check
her for injury but could see a small amount of blood. AB and Jane were still abusing Katja
viciously and taunting her about self harming. Police arrived at 22.45pm. AB and Jane were
quite belligerent with the officers. The police spoke to AB and Jane. Writer was talking to one
of the police officers and because she asked AB to wait when he asked for a spoon he threw his
bowl of food all over the floor. Police left at 22.58 stating the best thing would be to either move
AB or Katja. AB and Jane sprayed shaving cream all over Katjas door and continued to abuse
her. The ambulance arrived at 23.20. Roslyn had stayed with Katja until then. AB and Jane were
interfering with the officers entering the premises.
A phone call was made to police again but ambulance officers got onto the premises and said to
cancel the call. The ambulance left at 23.35pm. Writer went outside Katjas window and found
AB there listening to Katja on the phone stating he heard his name and started to threaten Katja
again . Writer went into Katjas room , she had called the police and they arrived at 23.50. They
spoke to AB and Jane again and left . Katja and Roslyn left the unit at 00.15. AB and Jane went
to ABs room. When writer let the window repairman in at 1.15 AB and Jane came and asked
where Katja was.
They both began yelling at the writer asking why does she get a drop off at this time when were
not allowed. Writer stated it wasnt about them at the moment and it was no concern to them
where Katja was. AB carried on to writer for a while but eventually calmed down, he was stating
he didnt believe me and all staff lie to him. Writer stated she didnt and it was his choice to
believe her or not. Writer asked if he was going to clean up the food he had thrown all over the
floor earlier. AB said no but when he saw writer start to clean it up as it was an OHS issue he did
it himself as he stated he felt bad seeing writer do it. AB asked for writer to come and talk to him
outside at 1.50 while he was having a cigarette.
Writer chatted and said he needed to find a better way to vent his anger. AB asked if writer
thought he was bi-polar, writer stated she was not a professional. He stated he might get tested,
writer suggested counselling and talked with him about having been before. She suggested
maybe he try it again as anger is only covering other emotions. AB said he would think about it
and he would talk to his case manager about getting assessed. AB stated he was going to bed at
1.58. Annafrid
Comment: I dont really need to say much!! The police and ambulance were called but the
clients did not change their behaviour in front of police. They also initially stopped ambulance
officers from entering and threatened and frightened a co-client so much that she threw herself
at a window! Next day was also a normal school day but none of these young people just
14/15 were attending any schooling.
AB was almost definitely a sociopath. He ticked every single box (no empathy, super ego,
controlling, manipulative and so on). Instead of his carers and the system through the CSO
and DHS being PROACTIVE about getting him assessed, this young 14-yr-old boy was the one

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asking a staff member do you think Im bi-polar maybe I need to be tested! What a
shocking indictment of our non care and the dereliction of our professional and legal custodial
responsibilities!
Monday
AB arrived to the unit sporting some new clothes. AB appeared to be happy with his new outfit
and looked happy to return to _________ St. AB looked around and asked who was located at
the unit. When the writer informed AB and asked if he got along with the current residents, AB
explained that he did get along with Rocco and Ty. AB replied that he did not want to bash
anyone if thats what you mean. Later AB met up with Caleb and Rocco and the three milled
about smoking cigarettes and chatting. AB then requested a drive to ________ Plaza to purchase
lollies. The writer ensured he had money and confirmed that there was no butt runs. After
purchasing lollies AB tried for a butt run but took it well when the writer refused. Later in the
evening AB hung out in Roccos room and later had red eyes. Brayden
Cont..
Writer heard noises and stuck his head out the door and found that food had been thrown all over
the unit. AB demanded DVDs after lock down then some milk later on. AB told that he cannot
be demanding stuff after lock down. Jackson
Tuesday
AB given wake-up call at 11am as requested but did not get up until 12:20pm. AB spent time
with Rocco and Caleb . Jackson.
(Comment: another example of the whole body clock issue and of them being completely out
of whack with any regular routines for teenagers. Here is a school day. No school, no planned
activities, no counselling. Sleeping in until after midday. Nothing creative, educational,
nothing healing).
Cont- when I arrived, AB was getting dressed to go into _______ to see Angie about his phone,
then returned to the unit to meet up with Jane. AB spent most of the afternoon coming and going
from a house up the road, he said was a friend of Janes. At one stage AB had a $20 note. He
told writer that had asked a lady for a cigarette and she told him she doesnt smoke and when she
came out of the supermarket gave him the money and said go by your cigarettes. AB left unit
with Jane and returned about hour later and they seemed substance affected, red tired eyes,
chatty. AB spent time interacting with Rocco and Caleb during the evening. Shavonne
Cont AB seemed in a good space when writer arrived coming across the road to kick the
football with writer and Rocco. AB ate a lot tonight saying that he enjoyed his dinner then
asking for two serves of dessert, shortly after he was seen to be cooking himself some noodles as
well and later eating some biscuits. He wore sunglasses for most of the night and was seen going
in and out of Roccos room where he socialised with Rocco and Caleb. Toward the end of the
night AB needed writer to open the door as he had snuck his friend Fred J into the unit and he
could not get back out. AB tried to demand that writer take him for a drive but writer refused as
it was too late, he stated it was to buy lollies but writer suspects that it was to get butts. AB left

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the unit on his scooter at around 10:30pm saying that he was going over to rob the shop. AB
returned shortly after with no signs of having robbed a supermarket. There were no issues over
night; AB has requested to be woken up at 12:30pm. Pete
Wednesday
AB is up and about around 11.30am this morning. AB chats with staff and Ty and appears in
good spirits. AB heads into town for a few hours and returns to the unit with staff at 2pm. AB is
in and out of the unit for most of the day and spends time with his friends. AB has been in great
spirits during the day. Marco
Friday
Writer gave AB some wake up calls from 11am onwards as per ABs instructions but he did not
get up.
Jane arrives at about 12.15pm and AB gets up and gets ready before leaving with her at 12.45pm.
AB in a great spot today. Jackson
Comment: Yeah. great spot! sleeping in until midday, having whatever food he wants at
whatever time, then going into town to score some weed or shoplift or get filthy butts from the
gutter or ashtrays. No schooling, no education, no therapeutic intervention, no healing A great
spot and wonderful care.
Cont AB seemed to be in a good space for most of today, Jane had been to the unit several
times to visit him and later he called her to say that he wouldnt be able to catch up with her
tonight. Unfortunately after dinner AB escalated quickly. Incident as follows;
AB did threaten to assault and did push staff members Mattias and Andy P, this happened after a
quick escalation where he became agitated at Mattias for not buying the right brand of 2 minute
noodles. Pete had stated that they would not be able to take him to the supermarket tonight and
instead put his request on the shopping list. He verbally attacked staff calling Pete a "fat lazy
dog" and threatened to "smash" him. Mattias gave him a few minutes to cool down by retreating
to the office, shortly after Matthew asked AB if he wanted to talk, to which AB replied "not to
you". Mattias then heard one of the cars being kicked at the front of the unit. Pete
Saturday
AB has a Miki card and has been given his pocket money. AB has been in a good space today, he
is interacting well with staff and co clients. Jane has been sneaking into the unit all day. Staff
have told Jane numerous times to leave. Paula
Today Ty told writer AB has been threatening him as well as taking Tys pocket money for his
own use. In the evening Rocco assaulted Ty. After the assault, AB and Rocco were threatening
Ty calling him a snitch. Whilst they were out the front of the unit threatening Ty, co-worker
Paula used quick thinking, running into ABs room while he was out the front to see if there was
anyone else in his room (as there had been suspicion earlier). Paula entered ABs room to find an

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unknown male, believed to be Fred D, smoking a bong. Paula swiftly took the bong off the
young man and brought it to the office. Writer had already called the police about the assault as
well as making them aware of possible drug use. While the police were here AB could not sit
still. Police spoke to AB and his un-known male friend and said if the unknown male did not
leave, and continued to come to the unit, a trespass notice would be issued. The police left the
unit with Roccos bong as well as ABs. AB then asked for a lift to a mates house corner of
Smith & Jones Streets. Ella
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Tuesday
Pietro given wakeup call at 8:55am. Up and had a shower had breakfast and watched a bit of TV.
Pietro wanted to leave early for his school so was taken at 9:52 and dropped off. Jackson
(cont)
Pietro returns from school program, has lunch and listens to his music before negotiating about
earning some extra pocket money. Pietro cleans the car and is aware that he can do this once a
week for a max extra $10 per week. Pietros school teacher contacted Angie (Program Manager)
today and has requested that Pietro not be dropped at tutoring early as class time is 10.30am
12.30pm. Daisy
Cont- When I arrived Pietro was at football training, When he returned to unit he was in good
space, interacted well with staff and co-client, with a few small altercations with Angus but more
about showing authority and trying to work each other out . At one stage Angus hit Pietro in the
penis area, after this incident Pietro tried to distance himself from Angus. We watched some TV
and he played some table tennis with Shane, the rest of the evening watching TV shows and a
movie. Pietro went to bed around 10.30. Shavonne
Wednesday
Pietro was woken by Angus this morning; Angus was harassing and bullying Pietro, (breaking
into the bathroom when Pietro wants to use it, slapped him on the legs with a kitchen utensil,
broke into his room, taking and touching his belongings, general threat) Pietro stood up for
himself but could tell he was hesitant to confront Angus. Shavonne
COMMENT: As per my recommendation, with one child with two staff, all of this conflict and
at least 80% of incidents in these notes, would have been avoided (perhaps 90%).
Cont... Writer arrived and shortly afterwards drove Pietro to ___________ Community Centre.
At 12:30pm Writer arrived to pick Pietro up and was asked to join an education meeting in
which there were representatives from DHS and ___________ School. Pietro listened very
carefully, was very respectful and thankful for the help he was going to receive. At the end of
the meeting Pietro went around the table and shook each of the eight peoples hands and
personally thanked them. On the way to buy football cards Pietro told the writer that he is being

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bullied by a co-client Angus. Pietro told the writer he could not take much more and had in fact
told the other Co-client Marco that he was feeling threatened and would assault the co-client if
the bullying continued. Writer discussed some of the things that Pietro could do to keep the
situation from ending in assault such as a safety plan, not teasing the co client himself and the
end result of police involvement if an assault took place. Pietro agreed to talk to staff and walk
away if the bullying continued. Pete.
Thursday
Pietro was at the Neighbourhood Centre when writer arrived for shift at 11am. Pietro returned to
the unit with staff member Shane around 130pm. On his return he joined in with Marco targeting
Angus. Pietro seemed to be taking Marcos lead on this. Even once staff had gotten Angus into
his bedroom Pietro and Marco continued to bang on his door and window, yelling abuse and
threats at him. Around 330pm Pietro began getting ready for footy training and he left the unit
with writer at 345pm. Pietro appeared to take a leading role at footy training and writer was
impressed with the level of commitment and focus he displayed. On return to the unit, Pietro
joined in with Marco and Angus playing the xbox. Staff and Marco spoke to Angus and Pietro on
several occasions throughout the evening as they were constantly carrying on towards each
other. Ricardo
Comment: A perfect example of bullying changing very often. One day child A is the target, the
next day Child A and B are joining to target and harass child C. This might continue for a few
days, then it will change again to C and B targeting A and so on
Friday
Pietro got out of bed around 9:10am. He came into the lounge to say hello to everyone and then
went to have a shower. After having a shower Pietro had his breakfast and then had a play of
ping pong with Callum. After the game Callum handed the boys their Easter present from the
unit, which contains Easter eggs and other chocolates, along with a drink bottle each.
Pietro then sat down to play video game with Benny and Angus. He mostly played with Marco
as Angus was being annoying to the boys. There was a bit of back and forth mouth off between
Pietro and Angus. They were on each others case most of the morning.
At lunch time (12:10pm) Pietro sat and had lunch with both boys and staff. He enjoyed the BBQ
lunch that Callum made for all and then continued playing video game with Marco before the
writer left the unit. Normie

Cont
Shortly after writers arrival staff and clients headed into the cinemas. Benny and Marco made a
point to sit away from Angus. Benny was well behaved throughout the movie. However, on
return to the unit, Pietro and Marco again began to bicker with Angus. Eventually Benny and

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Marco got their pocket money and headed down to the shop. They returned an hour later and
writer took them to get some takeaway. Marco allowed Pietro to sit in the front and he seemed to
enjoy the drive. On return to the unit Marco and Pietro headed back into Pietros bedroom. They
emerged just before 930pm and Pietro stated that they were going for a walk. Writer let Pietro
know that it was too late to be going for a walk especially him only being only 13. Writer let
Pietro know that he knew about the arrangement Pietro had previous to coming into residential
care; being that if he was out after 9pm he would miss out on footy training for a week. Pietro
acknowledged this but still decided to leave the unit with Marco. Fifteen minutes later Marco
called for a pickup and writer returned clients to unit. Marco and Pietro headed back into Pietros
bedroom. Ricardo
Saturday
Writer arrived on shift at 6pm Pietro and Marco and Angus were playing games. Bjorn (worker)
cooked a BBQ dinner. Pietro watched the football on TV with writer and the boys. Angus was
helping Marco and Pietro onto the shed roof at one stage. Pietro was in his room when writer
heard smashing glass. Writer came into the unit and Pietro had put a big gash in his right hand.
Pietro went to hospital with Bjorn until 11:45 pm. Jackson
Comment: There is no real explanation for this, but it appears he deliberately smashed his
window using his bare fists due to being angry or upset about something.
Sunday
Pietro spent time in his room but was kept up until 2am by Angus. Pietro was up at 9:40am.
Pietro given breakfast and an Easter egg. Pietro spent time playing games with Angus and
Marco. Jackson.
Cont
Pietro has been in a good space this evening. He has asked for his pocket money on a few
occasions however staff have told him he will not be getting it for a few days as he needs to pay
for the broken window he smashed. Later in the evening the writer noticed that as it got closer to
bed time (around 8.30pm) Pietro began getting hyperactive. Running around inside and outside
the house, blaring his music, trying to wrestle with both Angus and Marco. The writer had to let
Pietro know that this is the time to wind down. Bjorn
Monday
Pietro has been in a good space this morning. Again he has been bickering at Angus trying to
bully him and Angus is mostly ignoring it. Pietro played poker with other clients and staff in a
good space. Afterwards Pietro tried wrestling with Marco and Angus which ended up with
Angus upset and put a hole through the plaster wall in the lounge. Bjorn
Comment: again all these incidents would have been reduced to ZERO with one child by
themselves. In two days, one boy just 12 smashed his hand through a window and another
smashed a hole in the wall.

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Contd:
Pietro was wrestling with Angus when the writer arrived for shift at 5pm. They were both told to
cut it out and they did for a bit while staff were having handover. Once Marco stepped outside to
have a chat with Ricardo the boys continued hassling each other. The writer told them to settle
down if they want the Xbox power cord to be brought out. They both eventually settled down
and watched a show on TV.
Pietro played video game with Marco and Angus when the power cord was eventually brought
out. Pietro had dinner with all and then finished the night with a movie on TV. After shutdown
Pietro and Marco started mucking around again and Pietro hurt his hand that was already sore
from the broken glass on the weekend. Pietro cried and got angry about this for a bit but then
went back to have a chat with the other two boys. Normie
Tuesday
Pietro got up around 8:15am, along with Angus. He sat in the lounge to watch TV for a bit and
then had breakfast with Angus.
Pietro played video game with Angus and Marco for most of the morning, behaving himself
most of the time. Pietro had lunch and then continued playing video game with the other boys.
Pietro has also continued his wrestling with Angus as he seems to get into it as well. The writer
has told them both off about this and they have responded to this.
Pietro wasnt happy when the writer told him he was taking the power cord from the Xbox for
the night. He slowly settled when he knew he couldnt do anything about it. Normie
Comment: Pietro is 12Tuesday (it was April 2nd), would have been a normal school day. He
basically just played video games and wrested with the other boys, neither of whom were also
attending school. He did go to a school program a few days before, this was the tutoring which
he might have two or three times per week for two hours at a time. Thats 4 or 6 hours
education per week. A child in a regular school will attend school for 35 hours per week.
Cont..
Pietro was at the unit when writer arrived at 5pm. Pietro spent time with Marco and Angus.
Pietro complained about his hand hurting and was given new dressings. Pietro had dinner and
watched TV and played Video games. At 9:20pm Pietro, Marco and Angus went for a walk
stating that he was going to his girlfriend's place. Phone call from Marco to get a pickup from
Angus sisters house. Pietro and the boys arrived back at the unit at 9:20pm. Pietro spent time
watching TV and time with Marco and Angus and went to his room around 11:45pm Jackson.
Wednesday
Pietro was playing Xbox with Angus when writer arrived at 5pm. Both were interacting well and
continued to do so throughout the evening with minimal bickering. Pietro was very demanding
for food throughout the evening. Ricardo

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Thursday
When the writer arrived Pietro seemed in a good space. Both Pietro and Angus decided to catch a
taxi to Billy Joness house where they would hang out for most of the night. They caught another
taxi home which was paid for in a taxi voucher. Pietro did have red eyes however he said he was
just tired, it was difficult to see if he was substance affected as he was very evasive with
staff. Bjorn
Friday
Pietro was up and about today about 10am. He said he stayed up most of the night playing
Xbox with Marco but kept quiet. Pietro has been in a great space behaving well however is
finding it difficult as Angus is constantly annoying him. Angus and Rocco arrived at the unit
smoking pot trying to convince Ty to go with them. He refused constantly and found himself
being bullied by for a few hours by Angus. The writer spent most of the morning playing Xbox
with Pietro and also helping him to stay calm when being harassed by Angus. By about lunch
time Angus had settled and they both were getting along better. Bjorn
Comment: so Angus and Rocco are smoking pot upon their arrival at the State run care
facility for young children and this is more or less seen as normal. Apparently no action was
taken or police called. These are 12/13/14 year old children in our care in a house run by
DHS/CSO.
Pietro played some Xbox games in the evening with Marco. He then went out with staff and
other YPs Angus and Marco. Pietro interacted very well while out and appeared to enjoy his
time bowling. Pietro did need some direction on the drive back in the car about shouting out the
window. Pietro spoke in the car about staying awake until 7.30am in the morning and then going
to sleep for a half hour before playing the Xbox for the morning. On return to the unit Pietro was
play wrestling with Marco and needed some direction to stop as they may get hurt. Pietro took
this direction well and went to watch a movie in his room with Marco before bed. Edel
Saturday
Pietro got out of bed around 11:30am. He immediately came into the lounge room to see what
was going on. Angus began to become verbally abusive towards Benny who played a long with
this for a while but then could not hold himself back from being abusive back to Angus.
Pietro played video game with staff after Angus went back to sleep. He had breakfast and the
lunch later on. Pietros language was a bit out there a few times today but staff has been pulling
him up on this.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Thursday

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Ty is up late today and rises around 11.50am. Ty spends time lounging on the couch chatting
with staff. Marco
.. Continued
Ty must have gone back to bed because when the writer came on shift he was woken by Benny
at around 12:30. Benny was keen to engage with Ty and persisted in waking him up. When
awoken, Ty and Benny ate lunch/breakfast together and then spoke of going fishing today. Ty
has left his rods at his Pas so a kick of the football was decided upon instead. Ty, Benny and the
writer played football together. Ty practiced being a backman while Benny was the forward line
player. Ty has decided to play football with Benny for u\14s. Ty met the coach and attended the
training. After training Ty and Benny spent time together including a game of Poker. Al (worker)
and the boys together then with the writer ate dinner at the table. After dinner the boys played
together and wrestled. The result was Benny claiming Tys hat and taking it on the unit roof. Ty
responded by throwing stones at Benny while on the roof. Staff requested that Benny get down
from the roof and that Ty put down the stones that he was throwing. After several requests the
boys complied reluctantly while yelling abuse at each other and making threats. Then Benny and
Ty spent some time apart enabling them to calm down. The boys quietly watched television with
staff before getting full of beans and on good terms again. Brayden
Cont Both boys then left for a scoot at around 10:15pm, despite staff trying to encourage
them not to. They were in a good space though and appeared that they just wanted to expend
some built up energy, so staff not worried about their welfare particularly. ON-call notified at
11:00 when they hadnt returned. Both boys returned at 11:20pm and hopped straight into their
rooms. Al
Friday
When the writer came on shift Ty was up and out of bed. Ty ate his lunch and then interacted
with Benny when he returned to the unit. Ty was later told that he would be leaving _______
Street and would now reside at _________ Street. Ty did not take this news well and stormed
off to his bedroom. When he returned Ty was teary and questioned the move. Ty is fearful of
residing with Rocco considering previous altercations and threats. Ty requested to speak with
Angie and threw the telephone on the floor when he got angry. Ty asked to speak with Josefina
and his lawyer regarding an intervention order. Ty sat alone quietly and staff (Rudiger)
attempted to console him. Ty had a break from thoughts of his move by going to the movies. Ty
enjoyed a film and then several video games. On the return to the unit Ty had McDonalds for
dinner and appeared to be in a good spot. Later Ty went for a scoot with Benny. Brayden

Friday
Ty was at the movies when writer came on shift. After writer located them both boys were
playing games and we met up for take away. When Ty greeted writer he said he was upset and
pissed off that he was moving units and didnt want to go. We brought takeaway back to the

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unit and after a while both Ty and Benny went for a scoot. They called for pickup and Ty
informed staff that they had bumped into Rocco down the street. He said Rocco had been happy
to see him but was threatening to Benny and offered them some alcohol to drink which he
refused. Staff notified Rocco s unit that they had seen him. Ty and Benny spent the rest of the
night wrestling and playing around the unit. Ty was reluctant to hand over his scooter but did so
just at shutdown. Good choice Ty. Thanks mate. The unit went quiet till about 1.30am when
writer heard doors opening and closing and both clients running, slamming doors, calling out and
playing very loudly. Writer asked them twice to keep the noise levels down but they continued
on until about 5am. Mia.
Saturday Ty moves to new unit at _______ Boulevard.
Ty, Rocco and Paula went for a drive caught some frogs and now relaxing in good space. Ty
appears to have settled in really well, he is interacting well with staff and co client. Paula
Cont
Writer arrived at 6pm for shift and Ty had not long moved into _________ Boulevard, writer
greeted Ty and Ty was hanging around staff seemingly worried about Rocco and Claude. Writer
took Ty, Claude and Rocco to __________ to look for frogs and all had a good time. When back
at the unit Rocco settled in his room with Claude, both were listening to music. At 10pm Ty was
watching TV with staff when Rocco asked Ty to come into his room, Ty went into his room and
Rocco closed the door . Shortly after Ty came out crying with blood coming from his face, writer
went to Ty and he saw Ty crying and shaking with blood coming from his nose. He had been
punched in the nose by Rocco. Writer took Ty to the hospital and Ty was checked over by a
doctor and cleared him of any broken bone. Ty stated that Rocco had hit him for pretty much no
reason at all and that he was going to charge him. Ty was complaining of a sore nose, sore lip
and said his teeth were numb. Ty was scared when he came back to the unit and did not want to
stay at _________ Boulevard, but Rocco and Claude were in bed. Ty went to bed and nothing
further heard. Stevie
Comment: Another example of the chaos, dysfunction and lack of safety in Resi units for many
children. Tywas moved from his previous unit (reason is unclear) and moved to one where a
child resided who had a history of bullying and attacking Ty (I am writing this from the
experience of having worked with these boys in both units over a two year period). So, during
the first evening there, Ty had to be hospitalised after a violent assault. If any regular carer had
been asked if Ty should have been moved there, all would have said no. The Resi manager
would have been very aware of the issues too but for some reason he was moved there
nonetheless. This is the boy who was later moved into an expensive two bedroom, private
holiday unit/serviced apartment by himself as discussed in my main report.
Sunday
On arrival for shift Ty was still in bed. At 1pm writer checked on him and he was fast sleep.
Writer tried to wake him but no answer Ella
Ty has spent the day hiding in his room away from co clients. Writer called on-call and asked if
Rudiger from _______ St could come out and spend some time with Ty to get him away from
co clients. Annamaria said this would be a good idea. Due to Rudiger only having one client at

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_______ he was able to come out and spend some time with Ty. Ty was happy to see Rudiger;
he finally got up when Rudiger arrived. When Ty arrived back to the unit he went straight to his
room and locked the door. Ty called reverse charge from his room and asked if writer could
come down and get him, writer went to his room. Ty wanted writer to take him for a drive.
Writer and Ty went to the Botanic gardens and checked out the birds. Ty was relaxed once away
from the unit. Ty informed writer he has been assaulted by Rocco thirty two times. Ty said he
cant understand why he still has to live with him. Paula.
Writer and Ty went for drive to __________ is in good space when not in the unit. When we
returned, Ty went to his room and stayed there. Connor.
Monday
Ty was out fishing with Rocco when writer arrived for shift.
Upon return to the unit Ty had dinner and watched TV with staff. He then hung out with Claude,
spending time in his room and interacting with staff too.
Ty and Claude left the unit on foot at about 8.30pm returning at 8.50pm and went back into
Claudes room to hang out. Jackson
Tuesday
Ty took a long time getting out of bed this morning but got off to Tutoring all the same, a bit
late.
Ty seemed pretty tired but cooperated well with staff this morning.
Writer picked up Ty at 12 and we came back to the unit where Ty got his bike ready for his
repairing program.
Writer dropped him there at 1pm. On the way over Ty was quite chatty in the car and seems in a
good spot. Jackson
Cont.
Writer picked Ty up from the program and Ty said to writer that he didnt want to go to the
solicitors and instead go to footy training. Writer dropped him at footy training and he seemed to
interact well with the other kids. Writer got some of his belongings from ______ but he was
disappointed to see that he hadnt got his fishing gear back; writer told him that we would look
into it. Writer brought him back to the unit and helped him set up his room, he had dinner and
then went with Claude to ___________ to see Claudes girlfriend. Ty was picked up at 10.15pm
and then interacted with Rocco once back at the unit. Stevie
Cont. The writer agrees with the above statement. Ty spent some time in Roccos room
smoking, they were both reminded that this was not allowed but carried on regardless. Ty was
put under pressure from Rocco to stay in his room overnight but Ty resisted this request telling
Rocco I wanted to stay in my room. Pauley

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Comment: When Ty entered Resi, he did not smoke. He was only about 13 at the time the above
note was written. Also, the desire by Rocco for Ty to stay in his room overnight would have
almost certainly related to potential sexual abuse/sex power games by Rocco (again like in a
real jail).
Wednesday
Ty was woken at 11.30am; he takes an hour to get ready but is showered and has breakfast and
ready by 1pm for his outdoor ed program. Fred arrives at the unit to take him but he refuses and
after half an hour it was decided that he would go fishing instead. He arrived back at 3.30pm and
he hung around the unit for a bit. Pauley took Ty for a dive to _____ . Ty had dinner and writer
took him to play a bit of tiggy. Ty enjoyed this and he returned to the unit and watched TV with
staff remaining in a good spot. Ty made a phone call to his mum (Suzie) at 8.30pm, they had a
chat and Ty handed the phone to writer. Writer spoke to Suzie and she stated that it would be ok
for Ty to have access and to be brought over Saturday morning but staff are to search his bag
before he is brought over and to also speak to him about his behaviour when he is on
access. Stevie
Thursday
Writer took Ty to footy training and he had a ball. Ty came back to the unit and had dinner, he
watched TV for a while before meeting new client Ian. Ty started to show off a bit in front of
Ian. Staff then took Ty and Ian to ________for a game of tiggy and all was good. Once back at
the unit Ty is trying to get the attention of Ian and is showing off. Ty is trying to get Rocco to go
to bed so he could spend some time with Ian. At 11pm Both Ty and Rocco are not intending to
settle or go to bed while new client Ian is still awake. Ty settled in his room at 11:40pm. Stevie
/Paula
2:30am- Ty is now awake and being very rude to Dan.
3:20am- Paula witnessed Ty trying to break into garage by smashing the door with a log. Ty and
Rocco try to kick the side fence in. Large rocks and chunks of wood are being thrown at
windows. Police are called. All clients take off. Paula
4:03am-Clients back at unit.
5:30am. Ian GOES TO SLEEP. Rocco IN LOUNGE. Paula
Comment: Ians first day at the unit. Full of chaos, misbehaviour and even the police attending.
This is typical of older kids showing off in front of a newbie. Ty normally fairly wellbehaved was awake and being very rude to the staff at 2:30am and then at 3:20 am smashing
property and trying to break windows. He was showing off in front of new kid at Roccos behest,
and showing Rocco that he could act tough too.
Friday
Ty was hard to get out of bed as per usual; Writer likes to make a game of it and pretend to tip
water on him which usually gets him up and he response well to the game. Writer transported

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him to his grandmothers (Alvinas) new house in __________, Ty was keen for a chat during the
trip, we spoke about many things including his personal hygiene issues, he is concerned that he is
getting a lot of pimples and as he is very keen on several girls at the moment he would like to do
something about them, writer explained him pimples develop and encouraged him to shower
more and use cleansers and face washers regularly, He has requested we purchased him ProActive.
He spoke about girls a lot, he likes Sam and has known her for some time and is not happy that
Rocco is spending time with her and made threats toward him if he does anything to hurt her. He
also spoke about Maryanne from his mums house saying that he does not like her as much
anymore because he is In Love with another girl and is contacting her regularly on Face Book.
Alvinas new unit was easy to find and as per usual was very neat and tidy, she has a room set up
for Ty with a bed and wardrobe and pictures on the wall.
Ty will need to be picked up tomorrow by staff and transported to his mothers house in
______. Pete
Saturday Writer drove to __________ to pick Ty at 9.15am, writer arrived at 10am and Ty was
still in bed. Ty took an hour to get motivated to get up and pack everything up. We left his Nans
and headed for ______, on arrival Tys mum (Abigail) greeted us at the front of her house. She
gave Ty a list of rules that Ty has to abide by if he is to continue having access. Ty agreed to try
and abide by the rules and went inside. Writer spoke to Abigail and told her that staff would call
before leaving to pick Ty up Sunday night which was to be approx. 7pm. Stevie
Sunday
Writer went and picked up Ty from his mums. He seemed in good spirits.
There were two other ladies there as well.
Tys Mum encouraged him to make good choices this week so he could go back next weekend
and eventually for good.
On the way home Ty was anxious as he had not been getting along well with Rocco.
Once home he saw that Claude was home so he was relieved as Claude had told him that if
Rocco bothered him to tell him and he would deal with it.
Ty came for a walk with Rocco and Claude and they looked for butts before returning to the unit.
Ty spent time hanging with the other clients before settling down for the evening.
Writer was woken at 4.45am by a phone call from Ty who stated that he and Claude had gone for
a ride and had become separated in ________ near _______ St. He said he had had to stash his
bike somewhere and that a drunk man had chased them.

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Ty went straight to bed upon return to the unit. Jackson


Comment: These two boys had left the unit without the staff member knowing in the middle of
the night and were out at 4:45am.
Monday
Ty was woken by Rocco and Claude today who were both kicking on his door yelling to get up.
Once Ty got up Rocco and also Claude were threatening towards Ty. Ty was visibly scared and
looked uncomfortable and was keeping in close proximity of staff. Both clients were kicking
Tys door and demanding a phone number and if it wasnt handed over both clients threatened to
bash Ty. Jackson spoke to Ty and Ty told Jackson that he didnt want to stay at _________ st
tonight and he was scared for his safety. Because of the threatening situation staff decide to call
Tys mum and see if she could have him for one more night which she agreed to. On call was
notified to ask if this was ok and it was authorized. Dhs were notified and was again authorized,
Ty was taken by Jackson to ________ to stay overnight with his Mum at 12.40pm. Stevie
Contd
Writer dropped Ty at ______. During the trip writer encouraged him to make the most of
building a life outside resi and if he proved he could do as hes asked by mum etc then he may
start the ball rolling to leaving resi for good. Ty seemed to take this on board.
Ty is at mums on access.
Wednesday
Writer arrived to pick Ty up from his mums; Ty asked if he could stay at his nans for a couple of
nights. Staff called Tys nan and Josefina to organize. Ty is staying at his nans and will need a
pick up Friday morning between 9 and 10am.
Ella left to pick up Ty at 10.05am arrived at nans. Ty didnt want to get in the car as he thinks he
is going to assaulted by Rocco and Claude. He eventually got in the car and returned to the unit
at 12.30pm. Ty wants to go to his solicitors to get an AVO on Rocco. Rang On-Call nothing
they can do. They advised that if any incident call police. Ty really doesnt want to stay at the
unit tonight has rang his nan and said he will take off to a friends place if he has to stay here.
His nan said she would have him till Tuesday then mum will have him. Ty wants to talk to his
solicitor. Writer advised him that he would have to do that off his own bat. He just doesnt want
to live with Rocco. Writer drove Ty back to his nans where he will stay till Tuesday and then go
to his mums Ty is hoping for this to happen.
Ty said he is going to his solicitors when he gets back as I have told Ty if that is what he wants
to do he has to get his butt into gear because I think if he talks enough about it he thinks we will
do it for him. Zach
Comment: for some reason, this carer was telling a 14-yr-old who DHS/the SCO have full legal
responsibility for, that if he needs to see his solicitor about being assaulted and afraid in the unit,

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the boy must do this by himself. This seems very strange and appears to be an example of
dereliction of the duty of care by the carer.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
From various DHS Incident Reports.
AB and Adam did not return to placement. Writer rang AB at 10pm and AB said that he was on
his way to Melbourne. Writer asked him to prove this and he gave his phone to the train
conductor who confirmed this, he said that the train was almost in Melbourne. Writer could hear
Adam Kowolski in the background and AB said that Mick and Jane were with him also. Writer
called on call (Pauley), also DHS after hours (Karen), Karen said they would not get a warrant at
this stage but asked to be kept updated if writer found out their whereabouts. Writer contacted
Streetworks, ______ police station and also the transit police station and all said they would
keep a look out. Writer rang AB once again at 1.10pm and he said he was walking around
Melbourne but would not tell writer where exactly, he then hung up soon after
_______________________
Adam Kowolski and AB were in the side yard of the unit when they both started yelling abuse
and threats toward people that were in the backyard of the Girl Guides hall. Adam and AB were
told to stop however they did not listen even when they were told the police would be notified.
Adam was seen throwing rocks dangerously at the Girl Guides as well. Adam and AB threw
crates on the roof of the unit and then got up on the unit roof and yelled more abuse to the Girl
Guides.
_______________________
Writer arrived on shift and Adam Kowolski started to push Julian Smith around in the unit when
walking past him and making comments like Im going to bash you. Writer advised Julian to
ignore this and perhaps go and watch TV in his room. He went into his room however Adam
started banging on his door and told him to open up or he would bash him. Adam started calling
Julian his Bitch and Julian replied youre the one who wanted me to suck your dick last night.
Adam then escalated further clenching his fist and becoming aggressive so writer intervened.
Adam then went and did some colouring and writer congratulated him on doing this however,
AB stirred the pot even more by repeating to Adam what Julian allegedly had said not long
before. Adam got up and ran at Julian throwing punches and both clients got into a scuffle with
both clients throwing several punches. Writer intervened and separated the pair and things settled
for a bit. Writer then took Julian out of the unit and took him for a drive, during the drive Julian
disclosed to writer that Adam told him to suck his dick while they were alone in Adams
room last night.
______________________

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Adam and Roccos behaviour during the evening was quite heightened. Staff disengaged from
both Adam and Rocco. Whilst in the office Adam and Rocco were throwing things around the
yard and at the unit. Adam yelled out something about the unit car. The writer went to
investigate and found that the unit van had been broken into and moved half onto the road. The
writer found Adam and Rocco laughing next door. The writer moved both unit cars into the
garage.
______________________
Writer arrived on shift and Adam Kowolski was lingering around the office and pacing, Billy
was in an agitated state. Billy was making snap remarks at staff and staff ignored his negative
comments. Billy and AB walked out the front of the unit and proceeded to throw rocks at the unit
window. Pauley went out of the unit to tell them to stop throwing rocks at the window and Billy
threw rocks at Pauley to just miss. Not long after, Pauley was leaving the unit in the unit car but
Billy got inside the van and would not get out of the van while making threats toward Pauley.
Staff told Billy that the police would be called if he didnt get out, Billy still didnt get out and
staff then rang the police. Billy eventually got out but he then stood on the tow bar of the vehicle
stopping Pauley from leaving. He eventually got off and then walked towards Pauley and spat at
him. Pauley just managed to get his window up in time, Billy then came back inside and made
more threats to staff .The police arrive at the unit and speak to Billy and AB however could not
charge them for anything, Billy gloated to staff after the police left and said that he didnt get
into any trouble.
_____________________
At 8pm Adam asked for a ride to the ________ to ride his scooter. The writer informs Adam that
this isnt possible as it was too late and that he would not be able to scoot at the Shops. Adam
didnt accept this and began abusing the writer, stating that he was going to find the writer car
and burn it to the ground, called the writer various names like cock sucker, pedophile and that
the writer rapes little children.
_______
Writer was driving back to the unit from ________ when Adam Kowolskis behaviour took a
dramatic turn. Rocco was pulling at the steering wheel and honking the car horn while the car
was in motion and Adam suddenly pulled the seatbelt of the writer hard, yanking her backwards
away from the steering wheel and leaving her breathless. Writer pulled the car over and stated
that this was completely unacceptable and not at all safe. Writer stated that this was the boys last
chance to behave appropriately in the car. They were to keep their hands to themselves and off
the writer, but both boys did not accept this and writer felt very unsafe and exited the vehicle.
The unit was called for staff to come and take the boys in the other car. While waiting for staff to
arrive, Adam was extremely verbally abusive towards the writer, detailing all of the ways he was
going to get her back at the unit. Strategic and calculated threats were made about stopping
writer from getting into the unit, waiting for her outside the door, waiting for her to leave after
her shift, threats to wrap Rocco s scooter around the writers head, and general threats of bashing

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writer and getting her fired from her job. A call was made to another staff member for help and
once staff arrived, Adam refused to get into the other vehicle saying that he was getting back into
the car with writer. Writer refused to drive in a car with Adam in it so Adam slowly pulled off
the rubber seal from the passenger front door. He stared writer straight in the eye as he peeled it
off and was still making threats towards her and being overly verbally abusive. Dog faced slut
and fucking useless Cunt were the most commonly used. Writer attempted to get into the car to
drive away but Adam came around to the door and slammed it into the driver first, then opened it
again, then slammed into the driver once more before opening it and standing at eye level with
writer and still pouring out a continuous stream of threats and insults. Adam eventually decided
hed had enough and got into the other vehicle allowing writer to return safely to the unit.
____
The writer took Adam Kowolski to ________ for an access visit. Adam was telling his family
members about the bullying he is suffering from co client AB within the unit. During this
conversation, Freddy Q (Adam's cousin) made threats to harm AB. He stated: "Im going to
come to Blackburn and stab that kid. Ill get him and kill him for you Adam. No one will even
know its me?".
________
AB came out of his room panicking saying that Adam had been outside his bedroom window
threatening that he is going to stab him. Staff called 000 and also A/H due to threats of harm
towards AB. Police Officers (Smith and Jones) arrived at the unit and took down all these
particulars and said they would look around and would call the unit if they found anything.
Kezza asked if they could return Adam to the unit if he was found, and they agreed. Nothing
further was heard after 1am. Adam did not return to placement overnight.
_______
At 5.15pm AB and Adam Kowolski left the unit and arrived back at 5.45pm.They both had
dinner with staff at the table and Adam was quiet and lethargic, Adam appeared to be substance
affected. AB was very talkative and had blood shot eyes, he was also appearing substance
affected. Adam finished his dinner and then put his head down and closed his eyes, he laid there
for about ten minutes and staff encouraged him to his room but with no success. Eventually he
got up and noticeably stumbled into ABs room. Adam then fell asleep on ABs couch after this
with staff checking on him at intervals.
_________
At 8.30pm writer received a phone call from a young person by the name of Irene. Irene stated
that she had just received a call from Adam Kowolski and he had made several threats to harm
her. Irene said that Adam abused her calling her a fuckin slut and a retard because she went to
a special school. She said that Adam thinks she owes him money and must pay him back or she
will get bashed and stabbed. She also said that Adam threatened to go to her house and throw
rocks through her window. Irene said that she was shaken by this phone call and she feared for

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her life and didnt know what to do as she has already gone to the police about Adam and they
have havent done anything about it.
___________
At approx 9.30pm the writer heard AB and Adam yelling abuse at unkown people out the front
of the unit. The writer went to investigate and found AB and Adam abusing some unknown
people that had pulled up out front the unit in a car and a teenage male and female on bikes. The
writer told AB and Adam to head inside. After more abuse both boys enter the unit and the car
leaves. AB stormed to his room to get a weapon. The writer attempts to remove the weapon and
calm AB, however this was unsuccessful. Staff called ________ Police whilst the writer deescalated the situation and removed ABs weapon. The writer talks with both boys about
appropriate behaviour when in the community and also the ramifications if the incident had of
got out of hand. Both AB and Adam apologized and settled themselves.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Saturday
AB went into the unit and threw the Christamas tree and other items around the unit. AB
smashed glass against the unit wall and threw a 2 litre bottle of milk on the floor. When asked
why he was behaving this way he said because he felt like it. AB continued to escalate and
smashed several items of property in the unit. AB threw a glass at the office door and it shattered
immediately. Staff decided to disengage and stay in the office at this stage as he was clearly
agitated and it was not safe to be out on the floor. AB tipped over the entire refrigerator making a
huge mess with yoghurt and other food that was in the fridge. AB also smashed a number of
smaller items, namely crockery. Staff contacted 000 and police attended within 5 minutes of the
call. AB had already left the unit when they arrived and staff did not see where he went, as staff
were bailed up in the office as he went on his rampage. The police took a number of photos of
the damage and asked if it was policy to have him charged. Staff explained that he needed to be
charged. Police said they were going to attend at ABs mums house and he would be charged.
Once the police left, Brayden contacted on-call and then all three staff (Brayden, Billy and the
writer) proceeded to clean up the mess and damaged items. The floor was very slippery and Billy
slipped in yoghurt and fell onto one arm trying to break the fall. It was very painful.

Cont
I agree with aboveLater on AB asked to do work for $10.00 and was told no as there was
a lot of property damage and he called Writer a fucking bitch. Then Billy asked to do something
for $5.00 and was told no, they then both left the unit for half hour and when back AB and Billy
would not let staff close the office screen door which was accidently left open by Writer. At

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11.15 AB told Writer he was leaving and a few minutes later he was back. At 12.15 there was
very loud banging coming from the unit and outside lights were going on and off. Writer asked
AB and Billy what the noise was and AB told her that he got someone into the unit and wanted
to let them out. But it turned out this was a trick and when Writer opened the front door Freddy F
was outside and AB then went outside and said he was going to his place and may not be back. A
phone call was made to on/call and then with advice from Pete at O/C the Police were notified.
Unit Quiet at 1am ..John
Sunday
Writer arrived on shift and was told on handover that AB had absconded to Melbourne and had
been placed in emergency placement. Writer rang on call and DHS After Hours. It was decided
that writer would go and pick him up. Writer left and once writer arrived staff told writer that he
had absconded once again with one of their female clients. Writer waited two hours and then was
informed by DHS that writer could return to Ballarat and a warrant would be raised. Writer
received a call from the Melbourne unit at 5pm to say that AB had returned. Writer then double
backed again to pick AB up. AB presented well but looked tired and a little vague. AB chatted to
writer on the way home and returned in a good mood at 8pm. Stevie
Continued.
AB and Billy asked the writer if she could take them out to buy them a lighter. The writer said
no, so they began trying to pressure Brayden to take them. We tried to explain to them that we
cannot take them to get a lighter and as a result AB became abusive to the writer calling her a
slut several times. He then called his mum and had her come to the unit to bring him a lighter. He
said to the writer Dont worry Kezza you slut, my mum is bringing me one. He then went out
the front of the unit to wait for her with Billy. Kezza
AB said that whilst he was in Melbourne he had a fight with Freddy F and they were at some
house and he was going to smash Freddy Fs head in. He said he went for a walk and was then
picked up by the police. Kezza
Tuesday
AB awoke around midday and announced that he had vomited in the unit last night as a result of
drinking Bourbon alcohol. When asked where he drank alcohol he stated at a friends house.
Billy made comments suggesting that he too had been drinking alcohol with AB. AB requested
and received a couple of bacon and egg sandwiches for breakfast and was appreciative. AB later
requested a drop off at his mothers but she was not home. When AB telephoned his mother she
informed him that she was currently in Yackadanda which appeared to be news to AB.
AB and Billy asked about going swimming, going to the movies and attending water slides.
There was no activity decided upon and the two hung around the unit and claimed to be bored.
AB had a shower and then helped the writer install/replace the television he had previously
broken. The writer helped AB prepare for a telephone call to a potential employer. AB called and
left a message with the owner of a Newsagents who has displayed interest in help AB with a job.
AB will call once more tomorrow. Later in the evening AB requested to go to the movies but
there was not an appropriate movie and or time for him and Billy to attend. It appears AB and
Billy will spend the remainder of the evening in ABs room. Brayden/Christine
Wednesday

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AB was demanding writer to get him the phone and food. AB went to shops with writer to get
some meet and salad for dinner. AB demanded pies. Writer did not get them as there was some at
the unit. AB came back to the unit and demanded to be given the supermarket corporate account
card for the supermarket. When writer refused, AB came into the office as other staff had not
locked the door. AB was blocked from getting into the fridge and cupboards and writer
demanded that he and Billy to leave the office. When they refused, writer rang on-call who said
to call the police. AB then took the car keys from the desk. When the 000 was called, AB threw
the keys on the floor and left the office shouting at writer. AB demanded a lift to his mums
house. Writer explained that he has just been yelling at staff and why should we take him. AB
and writer talked about his behaviour and writer agreed to take him to his mums. AB apologized
to writer for his behaviour. AB called at 10:20pm for a pick up. Writer picked him up
accompanied by Billy and AE. AB had a shower and was give $5 pocket money. Jackson/Billy
Thursday
AB was up at 11am and was dropped at his mums by request. He returned to the unit at 3.10pm
with his brother Tom. AB is quite hot and angry and taking it out on staff. It takes him a good
hour to settle down and is intent on arguing with staff and trying to win each argument. Writer
took him and Billy to the shop to get some groceries and when back at the unit he requested
spaghetti bolognaise. He had dinner and then was quite content after this. Staff help prepare him
for his job interview and also get his resume completed. AB did some boxing with Brayden
and remained at the unit until 10pm when he left on a green scooter. AB returned to the unit at
12am and then knocked on the staff door at 12.20am asking writer to wake him at 9.30am. Stevie
Friday
AB is up and about at 9.30am this morning to get ready for his job interview at the
newsagency. AB showers and dresses very appropriately for his interview! Well done pal! The
writer takes AB to his interview. AB appears a little nervous but after a few hints and tips from
the writer, was at ease. AB was successful and earning a trial this Sunday 5am10am! Congratulations lad!. After the interview AB returns to the unit and relaxes watching TV
and has a mini snooze before heading to his mums. Great day with AB! Marco
Continued
AB returned from his mums at about 8.45pm. He hung out with Alex for the remainder of the
evening and seemed to be in a great space. He was still up and about at lock-down. Kezza
Saturday 05/01/2012
AB is knocking at the office door at 12.40am and asks for a bottle of water. The writer explains
that she had asked if there was anything he wanted just before lock down and that she wasnt
going be getting back up to get him anything else so if he wanted anything he needed to ask now.
He seemed to be just toying with the writer making he look for things that werent even here,
which he knew and thought was funny. He was back at the door with AE at about 6.20am and
seemed to be bright and wide awake. He was babbling on to the writer about how he and AE had
been awake all night writing rap songs about Billy. He said in the lyrics they talked about slitting
Billys throat, the writer told AB that its not funny and that he and Billy have been getting on ok
so why start picking on him now, just because Alex is back. He said yeah youre right. The
writer made some remarks about how he had managed to stay awake all night and not be tired.
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When Christine arrived for shift she also noticed that AB seemed pretty lively for someone who
had been up all night and she asked him if he was on shard, which he smiled but then went and
told AE what she said and they both then told staff they dont do that anymore as they have
learnt their lesson etc, but Billy later told staff that he and AE had taken ice and had been awake
all night. Kezza
Cont.
AB went to bed at 12 am and woke up at 5 pm. When the writer came on shift AB appeared to be
in an ok spot. He was lively and spoke about his first day at work tomorrow. Perhaps AB has
some pre-first day nerves. It was suggested that AB attempt to get and early night before his 5
am start at work. A taxi was booked and his clothing appears to be organized. AB requested a
drop off to visit his mother in the evening. He returned later in a good spot interacting with staff
and Billy well. Brayden.
Sunday
Writer on shift at 9:15. AB was picked up from his first day of work at 10:00 and arrived back at
the unit excited, chatty and eagerly answered some questions about work. Great stuff AB!, Hope
you stick with your work and that it goes well.
After returning from McDonalds with co-staff member (he was given a breakfast treat as a
congrats for his first day of work), he watched a bit a cricket with both staff. At around 11:00, he
banged on co-client (Billy)s door and Billy got up not too long after looking half asleep. About
15 mins later, both boys were back in their rooms. At around 11:30, AB suddenly escalated
relating to YC, saying that Billy had given him lip and that is why he was getting angry. He
was encouraged to go for a walk to try and calm down, but got increasingly escalated and took
two kitchen knives and attempted to break in to Billys room witnessed by writer. He also kicked
Billys bedroom door very hard about 15 times. He then went around and was banging on Billys
window and then from the inside, did get into Billys room and broke some personal property
(TV knocked on to the floor and this is now not working and broke his mobile phone in two) he
also hit Billy on the leg. On call were called (11:50) and advised us to call police. Police arrived
at 12:00 and took a statement from Billy about broken property (phone and TV) and
threats. After police left, Billy went for a drive with Brayden. Billy was in a calm mood and in a
pretty good space but had indicated quite clearly to the police and staff that he doesnt feel safe
here and that he wants to leave or for AB to have to leave. PQ/ST
Post-script: The notes end here. But I was working in this unit at this time and AB stopped
working at the Newsagents after two shifts.
______________________________________________________________________________
______________________________________________________________________________
___________________________________________________________________________

WEDNESDAY
When I arrived, Birgit was at the pool with the other co-client they called for a pick up at 6.30pm
when I arrived at the pool the girls werent out the front. Writer parked the car and went into the
pool, they werent inside either so writer called unit and the girls suddenly appear
walking towards writer. Birgit spoke in a grumpy voice: what are you doing here we wanted
Iris to pick us up. Writer explained Iris was on business I am picking u up. We returned to the

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car and the girls were very thirsty and asked for a drink. Birgit had chicken and salad for dinner
and is now watching TV. Shavonne
Cont Birgit had a good night watching TV and interacting well with staff, singing and playing.
However when writer left room to take a phone call, Birgit then for no apparent reason and in an
absolutely unprovoked attack, poured vitamin E cream all over the staff member. Birgit was
asked to stop but Birgit would not and would not let the staff member into the office. The staff
member then finally had got away when the other staff member on shift had come out and tried
to stop Birgit from continuing on with the behaviour. The writer then disengaged from the Birgit
and remained in the office until I was free to make a safe get away. It was lucky for the staff
member that the Police had arrived, so that the staff member could safely get to her vehicle and
leave for the night Iris/sharyn
Comment: while the notes arent extensive, they demonstrate the unstable and sometimes
dangerous situation staff are faced with. And most staff are completely untrained to deal with
violent and aggressive children.
One minute Brigit was singing and playing. The next, she was assaulting a staff member.
Although pouring cream on someone can be seen as not particularly dangerous or threatening,
clearly the staff member knew the child well and saw this behaviour as likely to be just the start
of something including possibly leading up to a vicious assault and felt that she needed to leave
the unit as soon as she could and make a safe get away.
_______
Thursday.
Writer advised Birgit that the police were here to talk to her about the previous night. Birgit
started laughing and ran to her room and she had a rude manner towards the police and writer.
The police tried to speak with her but she refused and the police told her her options and then
talked her around a little. She was still swearing and abusive toward police and started to
verbally abuse writer and said she would not speak in front of writer because shes nothing but a
fuckin bitch just like the rest of them. Al arrived and writer asked Birgit, now that Al was here
would she co-operate with the police?. She agreed and her statement was taken.
After the police had left, Birgit settled but she was a little worried as the police also questioned
her about the older male Jack D who had been hanging around Resi kids in the area. She was
worried that the other girls would find out and bash her. She told writer that there was still a lot
of stuff about Jack that she didnt disclose. Writer reassured Birgit that there was only her, the
police and the staff member who new what she had disclosed and no one else knows. She
seemed to relax a little then. Writer told Birgit that co-client Janine was on her way back to the
unit and so Birgit decided she should go to her room. Shavonne
Cont writer on shift at 11:00pm. Birgit had settled just as writer arrived as Police had arrived
to interview her over a previous assault and other matters. Writer sat in on her interview with the
police in which she was asked about an assault on a staff member the previous evening and a
broken window as well as the issue of co-clients and a relationship with an older male. Birgit
was quite good in the interview and provided some useful information but said that she wasnt
prepared to give evidence about the relationship issue with the male via a signed statement,
because she would get bashed as the others would know it was her who provided the
information to the police. Birgit then chatted to staff for a bit and went into bed at 12:20. She
was quite and did not get up all night. Al

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Thursday
When writer arrived for 8.30am, shift Birgit was in bed asleep. She got up about 9.45am. Birgit
was not in a very talkative mood but when she did talk it was snappy and rude towards
writer. Later on when Paula went into head office to get petty cash writer was sitting with Birgit
in the lounge. Her mood had changed and she was joking and mucking around. She started to
show off her gymnastic skills and we talked about the holidays and how excited she is about
going home to see the family. The unit phone rang and when writer started to talk on it, Birgit sat
on writers knee to stop writer from leaving the lounge room. Writer went into the office and
Birgit started asking for cooking ingredients and demanding other things. When writer asked her
to wait while she finished the call she started to yell and bang things. While writer was with
Birgit she was fine but when writer became distracted or busy with other things Birgit became
upset and angry. Birgit noticed that Janines bird hadnt had any water so she cleaned the cage
out and put fresh food and water for it. Well done Birgit, very caring of you to do that. Mia
Cont .
Writer went to pick Birgit up from ______ and Birgit would not speak while still in the building,
however when we got into the car, Birgit started on writer about being a liar and demanding
maccas icecream as another staff member had given her the money to have it. Birgit continually
played with the wipers in the car while travelling along. Nothing writer said or did was correct
according to Birgit. Birgit went to bed around 10.15. Francis
Friday
Birgit woke at 10:15 she seemed happy and chatted with the writer on the veranda and said she is
looking forward to Xmas as Birgit is seeing her Mum and Dad. She then explained her behaviour
towards staff to the writer.
Writer listened to Birgits concerns and explained you cant always have you own way and
hitting out at people doesnt solve the problem. Birgit was polite and funny sharing thoughts with
the writer. Birgit has a very active mind and is stimulated with talk and a patient ear. Fred
Birgit appeared to be in a good mood when writer arrived on shift. She was very excited as
worker Fred had bought her a guitar and she was able to pick it up between 5 and 7 tonight.
Birgit became very insistent that we leave straight away and started yelling when told she had to
put on shoes before we went out. Birgit became further agitated when Mia was going to take the
white car to pick up Jane. Writer and Mia swapped cars however Birgit continued to yell abuse at
Mia.
Once in the car, Birgit insisted having the music up to full volume stating that all the workers
let her do this. Writer asked Birgit a number of times to turn down the music, Birgit refused
yelling at writer, so writer turned the car back to the unit and told Birgit that they would not be
collecting her guitar until writer and she had agreed on a volume for the music. This agreement
was made however not before Birgit had yelled at writer some more and called her a fucking
bitch. Birgit remained annoyed on the way to the music store however with some distraction
soon got over this and the rest of the trip went without incident.
Birgit remained in a really good mood and was interacting very well with staff until about
9:15pm when writer tried to enter the office. Birgit prevented writer from doing so and then
placed her mouth over the lock. Mia was in the office on one side of the door while writer was
on the other and both tried to negotiate with Birgit and distract her however she would not move.

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Writer attempted to go around to the other door and then back again however Birgit ran ahead
each time blocking writer. Birgit appeared to give up at one point however as soon as writer
attempted to close the door after entering office Birgit tried to barge in. Writer placed herself
between Birgit and the office with Birgit continuing to attempt to crawl through on the floor.
Birgit then started to pinch writer hard on the feet and arms and kicking writer on the legs.
Writer lifted Birgit by her arms while Mia lifted her legs and moved her out of the way of the
door. Writer was able to get into office however could only close solid door, not the security
door. Birgit continued to bang on this for about 10 minutes threatening to break the glass. When
Birgit moved to another section of the house writer was able to close and lock the security door.
Staff remained in office for approximately 45 minutes allowing Birgit to calm down. When staff
came out Birgit was fine with Mia however was still showing animosity towards writer. By the
end of shift Birgit was engaging well with both staff and clients. Mia
Saturday
When the unit shutdown at 12midnight, all the girls sat outside with the music blaring, yelling
and laughing. They ran around the house banging on doors and windows. They went to the staff
entrance and banged on the door for several minutes. Writer was lying on the bed awake and
could hear the girls whispering and giggling. They saw the security guards car and started to
scream and ran back into the house banging the doors. Mia
At 2.15am writer could hear Birgit knocking on the office door speaking to stand up staff (Al)
asking for her door to be unlocked. Writer was asked to come out and open storms door and get
a bucket as she was feeling sick. Birgit told writer that when she vomits she fills the bucket
up so she was concerned what to do if the bucket got full. Writer suggested she take the bucket
to the toilet and flush it if this was to happen. Writer unlocked Birgits door and saw her to her
room. Mia
Comment: At times, such as the above example, units had a sleepover staff, a Stand Up and also
hired private security guards, who would sit in their car outside between around midnight and
6am. This was in case staff needed backup or to stop a girl getting into someones car or leaving
the premise. This is another example of how if my recommendation was put into place, daily
running costs for the CSO/DHS would be reduced by a huge amount (by at least 50% but very
possibly up to 80%).
Often, the units would have at least one Casual Agency Staff which cost CSOs about $100 ph.
The staffing costs for the one night in the above example would be: 1X Agency staff from 11pm7am = 8 hours at $100 = $800, plus staff on sleepover ($75) plus security guard ($100 ph) =
$600. So, for one eight hour period in this example, the staffing costs would have been
approximately $1,475 compared with $75 for one sleepover staff. The saving would be $1,400. If
this was for just 3 nights out of 7, the saving would be $4,200. Multiplied by the same situation
occurring in just ten more units in the whole State, this would add up to savings in one week to
DHS of $42,000.
___________
Saturday
When I arrived Birgit was OK. She had just got out of bed, she got dressed and we went down
to the supermarket. When we returned from the supermarket, Birgit asked for her tablet and
demanded a bottle of water quite rudely. Writer asked Birgit if she could use manners when she
is asking for something. Birgit just continued demanding what she wanted. Writer went to close

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the office door and Birgit tried to stop writer from entering. Writer held the door tightly so Birgit
could not enter the office and Birgit lashed at writer hitting me on the arm/chest area. Writer
informed Birgit that I would not put up with this behaviour and told Birgit she needed to let go of
the door or I would have to remove her. She laughed and said whatever, as if u would. Writer
them moved Birgit away from the door and quickly closed it.
Writer left the unit with Susanne and Jane to go to Kmart and the pool when I returned to the
unit, I came in the back door and I could hear Birgit calling get off me. I came to the front door
and staff Roslyn and Elbeth were restraining Birgit. She was kicking and hitting and screaming
verbal abuse at staff. I asked Birgit to try and calm down so I could understand what she was
saying and so I could help her. Writer got Birgit away from Roslyn and down to the bottom of
the stairs. Birgit was still trying to get back to Roslyn to hurt her and still verbally abusing her
and Elsbeth. Writer took Birgit by the hand and guided her away from the stairs. She fell to the
ground and cried and rolled around saying she was hurt. Writer again asked her to try and calm
down so I could help her. She then turned to writer and started verbal abuse so writer disengaged
and went into office with other staff members and waited for police to arrive. Police arrived at
about 4:30pm. Police left at 5:00. Birgit settles after this and when Roslyn left. Shavonne
Comment: This is the young girl who was placed by herself in the holiday unit as described in
my main report.
Saturday
When the writer arrived at 8pm Birgit was out with Normie buying Dettol. They returned at
8.15pm and Sharon ran Birgit a bath to soak her wounds. Birgit had a long half an hour bath
and put her PJs on. Birgit listened to music in the lounge while the other clients were cleaning
their rooms. Birgit asked Shavvone for a massage. Jane and Janine entered the lounge wanting
massages too. Tammy
Sunday
When writer arrived for 11am shift, Birgit was still in bed asleep. All girls woke up shortly after.
Birgit was in a quiet mood, showing her scars on her arm. When writer asked how she got
them she proceeded to explain that staff member Roslyn had attacked her.
She demanded to be taken to Chemist to buy something to put on the scars. Writer explained
there was plenty of other things in the first aid kit and found some Calamine Lotion. All the
marks were scabbed over, there were no open sores or bleeding. Writer did this twice and Birgit
was happy about this. Birgit was a bit up and down all day. She stayed in her PJs and cleaned
her room. The writer offered several times to help with the room but she kept saying no I will
be fine. Birgit wanted a bath and asked writer for help putting Dettol and bubble bath in.
While we were waiting she started talking about last nights incident with Roslyn. She said she
had told mum and she was not very happy with me, but she said Roslyn shouldnt have done
what she did either. Writer asked what she meant and she said well, she hurt me. Writer
replied but you hurt her Birgit she was just defending herself. She said well she is an adult
she shouldnt have touched me, I know what I did was wrong but she shouldnt have done
anything. Writer said wellwhy did you try to stop her from coming in for?Birgit laughed and
said I just didnt want her here. Mia
Cont- when Birgit was going to bed she noticed the security guard out front and she went to
Janines room and informed her that he was there. The girls then decided to run around the unit

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inside and out, yelling and screaming, banging on the doors etc annoying the guard and being
verbally rude to him. Writer asked the guard to move from the unit to settle the girls, however
they followed him and kept harassing him. Janine returned to the unit and informed writer what
they were doing and writer called the guard and asked him to leave the area from half hour so I
could settle Birgit and Jane. They returned to the unit and continued to be very loud and noisy
banging around the unit. They settle around 1.50am; Birgit also asked writer if the guard said she
kicked his car door? Writer was about to say no when Birgit replied, it wasnt me it was
Janine. Shavonne
Monday
Birgit awoke at approximately 10:15 AM. Birgit was asked if she would like to go for a drive
Birgit didnt feel like it. Later the writer talked to Birgit about how she was feeling, Birgit
replied that she didnt like it here as the girls hurt her. Writer asked Birgit if she needed any help
with her behaviour. Birgit replied she had not seen her psychiatrist for some time. Writer asked if
her visits where frequent and if they helped with her anger. She replied yes it did. Freddy L
Monday
Birgit was in a reasonably good space for most of the day. She helped out Annamaria today
cleaning a bedroom wall to earn some extra pocket money. She asked for help to do her room so
she could get her pocket money, which writer happily did with her. Later we went for a drive to
see the Christmas lights and she ended up having a great time singing Christmas carols, making
up songs and giggling on the way back. Birgit asked for small ice-cream from Maccas as she
had her own money. She bought two and gave one to writer. She said here Mia, this is for you.
Writer thanked Birgit for her generosity and thoughtfulness and we continued singing and
laughing all the way back to the unit. A very nice end to the night. Thanks Birgit. The police
had been in the unit for a matter with another client and when they left at 12midnight. Birgit said
oh my god Stevie (staff) is here.
Tuesday
No issues overnight. Writer checked room at 7.30am and Birgit was in bed.
Cont.. Birgit has been in an excellent space this afternoon. Writer helped Birgit organise her
room and her wardrobe. Writer suggested we do some cooking together; Birgit was very excited
and decided to make dinner for everyone. Great job Birgit. Birgit has also had her hair treated
just in case. She spent time watching TV with staff, Paula /Shavonne
Wednesday
Birgit ran to the door this morning screaming. Paula asked what the problem was. Birgit said her
canary was dead. Paula made a box for her bird and we buried it under a tree. Birgit has been
very rude to co-worker this morning. Paula
Birgit greeted writer by stating go away fat arse, when Jane and Janine asked her why she said
that Birgit stated that she was involved the other day with Roslyn and writer sat on her legs.
When writer started to speak Birgit started to yell at writer shouting dont fucking lie you
fucking bitch then stormed to her room slamming the door. For the rest of the morning Birgit
ignored writer and if she asked for something at office door and writer responded Birgit would
shout I dont want you I want Nic. Birgit soon calmed down and was engaging well with
writer. At 1:40pm writer took Birgit in the car while dropping Janine off in town. Just outside
____________, writer thought Jane might be in the boot of the car, which was confirmed. All

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three girls decided to exit the car and walked off down the road, yelling and swearing at writer,
rather than return to unit. Janine rang for a pick up for all the girls at 3.30pm. Upon returning to
the unit Birgit immediately started calling writer a bitch for not driving the girls after discovering
Jane was in the boot. Nic
Wednesday
Writer went to pick up all the girls at the milk bar near __________ College at 3.40. On the way
back they discussed with writer about having a party at the unit tonight. They said they have
invited heaps of people, starting at 6pm till really really late. When we got back to the unit the
three girls got dressed in their bathers and demanded either bus money or a lift into the pool.
The request was denied as it was after 4pm and they were all on a car ban due to hiding Jane in
the boot of the car when they went for a drive. They all went out the front and at 4.30pm a taxi
pulled up and they all got in. the taxi sat there for a few minutes and all the girls got out. The taxi
driver had asked them for prepayment.
After a while Jane and Birgit and then ran to the front of the unit trying to break in through the
front door using a house brick and a sharp knife. They smashed a house brick against the door
handle of the crim safe door and used a sharp kitchen knife to try to open the lock. (IR done).
Writer called 000 while Nic called Angie to advise. Police officers Richardson and
Michaelson, arrived at 5.10pm, just as Sarita from ICMS was arriving.
The police questioned Jane and Birgit about the knife which they both denied having. Writer
spoke to them and gave them the opportunity to hand it over before the police took over the
situation. Birgit threw it down the hallway towards the police. Bob and Marco arrived to do
room searches which they did with the assistance of Sarah. Jane screamed her way around the
unit, generally being rude and disrespectful to other staff, trying to block Marco and Bob from
doing room searches. After the room searches staff sat in the office disengaging and discussing
the events. The girls were banging on the door and yelling out so staff went to the staff bedroom.
While we were there, a loud bang was heard then the office crim-safe door was heard to be
opened.
When staff investigated we all found that there was a large hole, about 30 cm (1foot) in
diameter in the wall of the office, between office and lounge room, beside the
door. (IR done)The girls all ran off squealing and laughing into Janines room. A short time later
________ Police again arrived, to take Birgit to secure welfare and Jane became hysterical and
distressed at seeing Birgit taken away in handcuffs. Jane kept blaming herself for Birgit being
taken away and staff did their best to assure her it had nothing to do with her or the actions of
today. Birgit was screaming what have I done now, I dont want to go and saying to Jane tell
them you did it, tell them you did it (reference to the hole in the wall). Jane and Janine yelled
abuse and swearing at staff and went into Janines room. They came out about an hour later and
started to engage in a calmer manner with both staff. Mia
THURSDAY
Writer spoke with Birgit this evening she was in good spirits and was excited because she had
got to speak to her real mother today. She spoke about her brother and 2 sisters, one she didnt
know of, and she was very excited about that. She also mentioned that her mother has got breast
cancer but they have caught it early. She wanted to know if anyone would be down to see her
and if so could we take some clothes down to her and make sure they are old one and none of her
new clothes please, and nothing with hood or strings. Birgit said that she was happy and sad.

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Birgit also said that her mother had said that she had bought Birgit a birthday and Christmas
present for the last 8 years. Birgit would also like to know if she could have contact with coclients. Shavonne
Writer spoke to Birgit on the telephone at 3:30 she said she was not happy about being in secure.
Thursday cont
Writer arrived for 4pm shift and shortly after a call came in from Birgit from Secure. She spoke
to Freddy L for a while then spoke to Jane and Janine. Jane was saying it was fucked that she
was in Secure and it said its fucked you are in there, it was all that cunt Roslyns fault for
calling the cops about the wall and the knife. Birgit replied no Jane it was not staffs fault, or
yours or Janines fault, it was all my fault. My DHS worker said I am here because I have
assaulted staff. It has nothing to do with anyone else so dont blame anyone else. It is all my
fault.
Birgit was on loud speaker on the phone and writer said hello to her. Writer also congratulated
Birgit on her maturity for accepting responsibility for her actions. She told writer she wasnt
sure when she was coming back but she knew it would be soon, and my real mum has contacted
a solicitor and is trying to get me full time. Writer asked how she felt about that and she said
she was excited but missed everyone here. Writer said we missed her too and looked forward to
her coming back. Mia
Saturday
Mia called secure to talk to Birgit but she was on another call at the time. Staff at secure
informed Mia that Birgits exit date is -------. Roslyn
Sunday
Writer called Birgit and she was talking to her mum on the phone so called again a bit later. She
seemed happy to speak to writer and Shavonne. She told writer her mum is coming tomorrow to
see her and she is very excited about seeing her siblings. She was busy in the craft room making
a present for mum and was happy because there is always something to do here, havent been
bored once. Mia
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Saturday 29/12/2012
At 1.15am Daisy called for a pick up from the pub around the corner from Janes mums
house. They were both there when writer arrived. They tried to get in the car with their lit
cigarettes so writer had to wait till they finished their cigarettes before we could take off. On
return to the unit writer noticed they had red eyes, slurred speak, giggled a lot and spent a lot of
time going through the fridge and cupboard for food. Writer contacted DHS A/H (Nancy) to
advise of their return. Mia
Writer checked client rooms at 7.00am and both clients were in their own beds asleep. Mia
Cont.. Daisy had a big sleep in this morning. Daisy was up and about at 2:00pm. Daisy is in a
great mood. Nice to see you in a good mood Daisy. Paula

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Saturday cont.
Daisy has been in a good spot all afternoon. Daisy asked if we could get some DVDs and the
writer at first agreed but after reading the hand-over found that both her and Jane are on a car ban
until Sunday. The writer explained this to Daisy and Jane but told them that I would drive in and
get the DVDs that they wanted. Daisy and Jane spent most of the evening in Daisys room
venturing out every now and then to chat to writer who was in the lounge. At about 8:30pm Jane
asked if the writer would take them out for a drive at 9:30 and the writer again reminded Jane
that there was a car ban until tomorrow. At 9:20 Daisy told the writer that her and Jane were
going for a walk around the block.
The writer asked if they would like me to join them but was flatly refused saying that they were
not babies and could go for a walk by themselves. At 10:07 the writer called Daisy on her mobile
but the call went unanswered. The writer then attempted to call Jane which was answered but
hung straight up. The writer then called Angie B (on-call) to inform her of the girls not being in
the unit. After the call to Angie, Daisy called the unit wanting to know why I had called. I asked
her how long they planned to be out and was told by Daisy that they were running around the
oval (Daisy did not appear to be out of breath), the writer told Daisy that if she and Jane have not
returned by 11pm then I would have to ring DHS. Daisy said she understood this. At 11:11pm
the writer called DHS A/H and spoke to Tracy who asked that the writer call her back when the
girls have returned and gave me her direct number. Roslyn
SUNDAY 30/12/2012
Daisy called the unit at 2:11am asking to be picked up from _____ in town. Daisy told the writer
to hurry as she was cold and wet. On the way out the writer grabbed 2 towels. As the writer was
driving into smith St, I saw Jane outside the public toilets. The writer drove into the carpark and
parked outside the toilets. Jane was no longer outside and a short while later Daisy and Jane
came out of the mens toilets. Daisy took one of the towels from the front seat and took them
back to the mens toilet and the writer could hear her talking to some boys (sounded more than
one), Daisy then returned to the car without the towel. On the way out the car park, Daisy kept
beeping the horn. On the way back to the unit Daisy said that she was hungry saying that she
didnt have any dinner (on the request of Jane the writer had made nachos for dinner and Daisy
had eaten all of hers). Daisy asked if she could cook something up and the writer told her that the
oven and stove top are turned off and will not be turned back on this late an hour. Back at the
unit the writer made sure there were snacks that the girls could eat and then bid them both a good
night. Roslyn
Comment: There was no extra notes or comments from the staff about the fact that Jane had
been with unknown males (more than one) in the mens toilets in a park in the middle of the
night! Apparently this was just seen as usual and normal behaviour.
SUNDAY
Writer arrived for 11am shift and Daisy was still in bed till about 1.30pm. Daisy was in a pretty
quiet mood all day, but generally quite respectful and saying please and thanks when asking for
something. After dinner the girls wanted to go for a drive. Writer and Shavonne discussed it, and
as both girls had been in a good space all day and been well mannered, we agreed we would all
go to the Park for a walk after dinner. When we stopped the car, the girls hopped out and left
us. Writer and Shavonne tried to talk them out of leaving; reminding them of their curfews and
that phone call would be made if they dont return.

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Writer and Sue arrived back in the unit and writer was on the phone to Angie and there was a call
trying to get through. When writer checked the phone at the end of the call there were several
missed calls from a private number and an abusive message from a private number. Shavonne
called Jane to see if it was her and she started to yell and swear at Shavonne saying it wasnt me
you fucking idiot Shavonne asked Jane not to swear at her and her reply was I will fucking
swear as much as I fucking want to so Shavonne hung up the phone.
Shavonne then rang Daisy and it was her who had been ringing and left the abusive text message
on the phone. She was concerned that she would not make it back to the unit before her curfew
but Shavonne assured her that as she had been trying to call and the phone was busy it was not
her fault and nothing would happen in relation to her curfew. She was back in the unit by 9.50pm
anyway. Mia
Cont when writer picked up Daisy she was visibly upset and her anger was directed towards
Jane. They had had a falling out and she didnt want to see and speak with her and said I might
do something I regret. Writer spoke with Daisy about this and her feelings and consequences
that may go with it. She replied it doesnt matter because she is shit scared of me and that is
why she wouldnt charge me and that is why she does what I say. Daisy also mentioned that
they had been to ________ st and they were at the toilet block smoking bongs with Jane and AB
and Tom and this is where Janine and Jane had their falling out, and that she had shouted them
the weed. She was unsure if Jane had had a bong. Daisy retired to bed. Shavonne
The Taxi driver also comment that the girls had called for a Taxi around two weeks ago from the
start of Pde and to be taken to __________ college. Driver asked for the money first and the
girls said no we havent got any but you can go get it from the unit. Driver refused and the girls
scrapped up $7.00 which nearly got them to the college. Shavonne
Monday
Paula woke Daisy at 9:00am. Paula gave Daisy four wake up calls before she got up. Daisy
didnt seem to be in a rush to catch up with her daughter. Daisy asked Paula to cook her some
toast. Paula informed Daisy we were running late for access and Daisy didnt seem to care.
Finally we left and picked up baby Miah. Daisy interacted really well with her baby. Both Daisy
and Miah were in a great space; Daisy appeared to be relaxed and really happy to be with her
daughter. Daisy changed Miah before we returned her. Well done Daisy. Paula
Monday
Writer arrived on shift at 6.30pm and Daisy appeared to be in a really good mood. She put on a
movie and writer and Roslyn sat watching it with her with Daisy and Roslyn had dinner. Half
way through the movie Daisy received a phone call from a boy called Billy and was chatting to
him until he asked her about injecting drugs and she replied that she had to move to a private
area as workers were listening. Daisy returned to the lounge stating that her new years wish had
come true and that she was getting stoned tonight. Writer talked to Daisy about staying safe and
away from injecting drugs. Daisy laughed and said dont worry he asked if I used them and I
told him no, I only use dope.
Daisy watched end of movie with workers and asked Roslyn if after she has a shower could
Roslyn drop her in town. Roslyn stated that she wasnt allowed, so Daisy asked to be dropped
near town. Writer helped Daisy dye her hair and Daisy proceeded to get ready to go out and kept
asking writer for advice on how she looked. At about 9.30pm Roslyn spoke to Daisy to ensure

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

she knew that staff would not be giving her a lift. Daisy became very angry about this yelling
and swearing at Roslyn and stated you knew how much I wanted this. Daisy continued to ask
writers about different ways of getting into town (asking for a lift for cigarettes, asking for taxi to
be paid etc) and was angry each time she was denied yelling and swearing at workers each
time. Ros

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Tuesday
Daisy called the unit at about 1:15pm asking to be picked up from the park. When staff arrived at
the park Daisy was not there and we drove up the street a little bit and saw Daisy walking down
from the direction of _______ St (where Janes mother lives) in the company of Tom.
On the drive back to the unit Daisy was very chatty about her night but found it hard to string a
sentence together and her train of thought appeared to be all over the place. Daisy stated that she
had not had anything to drink at all last night and then changed her mind and said that she had
had two sips of a drink that the writer had never heard of before and can no-longer remember the
name. The writer asked her about it and Daisy said that it tasted horrible and she spat it out.
Daisy also stated that she turned down drinks; pot and everything else offered to her but couldnt
understand why she had turned it down.
Then writer asked Daisy if maybe someone had spiked her drink and Daisy replied that nobody
couldve as she had opened the can herself. Back at the unit Daisy had a shower. Staff hadnt
heard much from Daisy for a while. Shavonne checked clients bathroom to make sure the she
was ok, but Daisy was no-longer in there and Shavonne saw that there was a new very large hole
in the wall.
Daisy returned to the bathroom and Shavonne questioned her about the new hole, Daisy denied
any knowledge of the hole saying it was there last night (staff did not point out that she was the
only client in the unit last night). Daisy told staff that she had just received an abusive phone call
from someone close to her but wouldnt say who although told staff that it was a male when
asked. When staff asked her what happened she said that her phone had rung as she was getting
out of the shower and that the person abused her (when staff had seen her on the phone she was
on the black one that staff believe she is using as a contact for her boyfriend in prison).
Daisy then asked if she could go get a maccas coke which she paid for herself. She wanted to be
dropped off at the pool and on the way said to staff what would happen if I was around a lot of
people taking drugs and someone put something in my drink and I drank it would I get any effect
from it when asked what was put in her drink Daisy indicated that she thought it was ICE.
When staff affirm that she would probably be affected Daisy said well there goes Miah. The
writer and Daisy then had some one-on-one.
Daisy and the writer sat on the grass by the lake and chatted, the writer noticed that her neck was
covered in hickies most of them very large. Daisy again told the writer that she accepted nothing
from nobody last night and couldnt understand why she was felling so buzzed.
Daisy also said that she found herself in the disabled toilets (but didnt say which ones) and that
she had been in there for about two hours and that she kept abusing people that kept knocking on
the door. Daisy said that even though she was really tired and has not slept since 9:30am
yesterday she has found it impossible to sleep, saying that every time she tries to close her eyes
she gets this sudden bout of energy and had to walk it off.
Daisy said that she walked most of the way from _____ in town to the unit. When the writer
asked if she was with anyone Daisy indicated that she was never alone. Daisys train of thought
was still impaired and she still couldnt string a sentence together and kept repeating herself or
couldnt find the right words to use. Shavonne returned to pick us up and Daisy then asked to be
dropped off at the shop where staff believes she is meeting up with Tom. Daisy did interact well
with staff was pleasant and speaking openly, but couldnt put her words together
properly. Roslyn/Shavonne

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Comment: Despite Daisy being ill and non compus mentus, staff appear to have dropped her in
town to meet with Tom who was the brother of another Resi child, semi-homeless and a known
drug supplier.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Sunday
Jane spent most of the evening lying in front of the TV and at one point fell asleep for about an
hour and a 1/2. When she woke she complained about her face being sore (she is badly
sunburnt). She asked for vinegar to put on her face which staff gave to her and then the writer
applied Burngel to her cheeks, nose and forehead.
Janine asked Jane if she would like to go to watch the carols. Paula took both girls to the park. At
the park Jane and Janine ran off on Paula and Paula returned to the unit alone. At 10:00, the
writer called Jane on her mobile to see how she was doing and to see if she plans on returning.
Jane told the writer that she was still at the park and that the carols hadnt finished yet but will be
coming back when they were. The writer did note that while talking to Jane that there were no
background noise to indicate that she was still at the park. Calls were made to on-call, DHS A/H
and police. The writer tried calling Jane again at 11:10 but got no answer. Janine called the unit
at 11:57pm requesting a pick up from the Aquatic Centre. When both Jane and Janine got in the
car their clothes and hair were very wet, they appeared to be in a happy mood but did not appear
to be substance affected. Janine told the writer that they got a lift out to _________ where they
went swimming in the river, Janine said that some guys kept looking at them and then told the
writer that her and Jane had stripped down to their bra and undies to go
swimming. Roslyn/Paula

Cont.
Jane has spent most of the day in Janines room and came out for some dinner which Jane did
not eat. Around 9pm writer took Jane and Janine out for icecream and to go look at xmas lights.
On the way writer stopped several times to ask Jane to put her seat belt on and stating if Jane
took it off one more time we would return to unit and she would be on a car ban.
While going though the maccas drive though Janine was abusive to Maccas staff and the order
was refused. While exiting the drive-though, Jane opened the car door and said Im getting out.
Writer stopped the vehicle and Jane got out and Janine followed. Writer asked them both to
return to the car but both Jane and Janine refused. On call was notified and AH/DHS. A car ban
has now been imposed on Jane for 48 hours. Francis
Tuesday
Jane was in her room when the writer arrived. She did not respond when the writer wished her
happy Christmas. After Annamaria left, Jane asked to be taken to see her brother. The writer
replied that due to the car ban imposed the night before, transport wouldnt be possible until 5pm
and then it would be to her mothers. Jane became abusive yelling fuck off you cunt etc then
walked off. Jane requested that Christopher open the laundry so she could get her supplies to do
some painting while she waited to be taken to her mothers. Five minutes later workers

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

discovered that Jane had written in huge green letters fuck all u kunts on the dining room wall
and also I hate fucking X-mason two places in the hall wall.
There was also paint on the wall in front of the toilet and on the mirror and shower door in the
bathroom. This has since been cleaned off by Christopher. Jane asked again to be taken to see
her brother several times and was abusive each time the writer explained why she couldnt
transport her. She then requested $50 Christmas money to buy phone credit, saying that she had
only spent $100 of the money she gets from the unit for Christmas. The writer checked with
Angie, but as Angie nor the writer knew about what had already been spent on Jane, the writer
advised Jane that she couldnt give her any money. Jane again hurled abuse at the writer and
Christopher. Jane spent some time with Janine and her baby before both Janine and Jane
requested to be taken to the park with the baby. The writer told Jane that it was time to go to her
mothers and Christopher transported her there. On the way there, Jane told him that she was
allowed to stay there as long as she liked. Sarah
Wednesday
When writer arrived on shift found a new hole in the wall near the office door and the ceiling in
the kitchen had been sprayed with what looks like paint and spattered with food. Jane was in
bed. Jane got up around lunch time and showed writer what uncle gave her and she then made
toast to try the nice jam she had been given. Jane seemed to be in a good space. Francis/sharyn
CONT- Most of the afternoon Jane was being demanding to writer, telling writer to do what she
says and hurry up about it. Writer explained to Jane if she would like something done for her, it
would be appreciated if she used her manners and stop demanding things and writer would be
happy to accommodate her requests. Jane left the unit at 7.40 pm by Taxi with co-client Janine.
They called the Taxi as they were on a car ban, and staff refused to take them. They said they
will call when they want a pickup. Paula called Jane, Janine was in the back ground and told
Paula to get fucked and they were not coming back tonight, and that they were stoned.
_________On call and DHS have been notified. Shavonne /Paula
Jane arrived home at 1:10am in a taxi with Daisy. Paula
Thursday
Jane was in bed until around 12 noon and got up in a good space, telling writer she had been out
the night before getting stoned with Janine. Jane informed writer her mother had rung and was
coming to pick her up in 45 minutes to take her shopping. Mum came around 1.30 and Jane left
with her. Francis
Cont- writer also reminded Jane of her curfew And she replied I am never home by my curfew,
so ha. Both times writer had Jane in the car today she lit up a cigarette. Writer stopped the car
both times and asked Jane to hop out or put it out - both time abusing writer. Back at the unit she
had a bath and then came into lounge area had a chat with staff and the headed to her room at
shut down. Shavonne
Cont- Jane and Janine were still up at 2am writer did a welfare check. Girls were in Janines
room and I spoke with Janine and then Jane came out wanting to know what I wanted. I
explained to her I was doing a welfare check as it was late and might be good idea for them to go
bed. Both girls seemed reluctant to let me near Janine bedroom, and closed the door when they
came out. Writer returned to staff bedroom, they seemed to settle around 2.45am Shavonne
Friday

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Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Writer arrived for 4pm shift and Jane was sitting in the lounge-room with Janine and worker
Marco. When Marco left Jane started to demand things from writer, swearing and yelling open
my fucking door get me the phone. Writer asked Jane to use her manners and speak better to
worker, she said I dont have to.
At 6.30 we all went to the roller skating rink. On the way, Jane had to be told several times to put
her seat belt on and she also had her hands out the window a few times. We pulled the car over a
couple of times and she was advised if she did it one more time we would turn the car around
and go back to the unit. When we arrived at roller skating rink the girls separated after a while
and went and hung out with their own friends. Staff from ______unit were there and AB was
there unsupervised and talking to the clients. Staff were talking to their current clients about AB
when Jane started to defend AB from Anna. Jane started to be rude and threatening to Anna,
saying that AB was going to bash her if she didnt shut up.
Anna calmly asked Jane to keep out of the conversation as she didnt know the whole story and it
had nothing to do with her. Jane started to raise her voice and swear at Anna again. Writer
stepped in between Jane and Anna and asked Jane to move away and keep her voice down and
stop swearing at Anna. Jane then turned to writer and said I am not fucking coming home
tonight anyway so you dogs may as well go now. Roslyn pointed out that if they left the roller
skating rink without staff that they would probably be banned the next week. Jane started to yell
at Roslyn and said what, you think you can stop me from coming here?
She then went over to a group of kids and started to point at writer and other staff saying they
are just dogs, they are cunts, I fucking hate them all. She moved away from the staff and went
outside. At approx. 9.10 both Jane and Janine came over and said quick we have to go now,
quick quick when writer asked what was wrong they said the cops are coming, come on lets
go. In the car, Janine said we left early because there was going to be a fight and we didnt
want to get involved. Staff congratulated both girls on their wise choices and when they asked if
we could stop and get an ice-cream from maccas we said yes. Again Jane had to be told to put
her seat belt on. Staff reminded them that Janine was not able to go through drive thru so Jane
offered to get out if we parked at the door and go in and get the ice-creams. When the car
stopped, staff had been tricked and both girls jumped out laughing and said goodbye. When we
arrived back at the unit DHS A/H was notified and ________ Police and ONCALL Mia/Roslyn
Sunday
When Jane and I left this morning from the unit to take Jane to breakfast before access, Jane
didnt say goodbye to Janine when she walked out. I asked her in the car why she wasnt
speaking to Janine. She said Janine went off at her last night when they were at the back of
_________ St unit because Jane called out to AB and Janine doesnt like AB.
I noticed Jane had a backpack full when we left. She said she just had a towel and clothes in
there for later today. I asked her what her plans were for tonight and she said she was meeting up
with a female friend and catching a bus. I asked Jane what time shell be back and she couldnt
tell me. Jane said they will be going swimming today. Jane said she isnt seeing Janine later and
wasnt sure of Janines plans for New Years? After breakfast I dropped her at mums for access.
I asked Jane to make sure she keeps in contact with the unit today and to remember her curfew is
6pm. Tammy
Monday

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Jane returned to the unit briefly at 1:24pm but was gone again by 1:30pm. The writer called Jane
on her mobile at 8:57pm for a safety check, there was a lot of background noise and it sounded
as if she was at a party. Jane assured the writer that she was safe and was having a good time.
When the writer asked if she had any plans on returning to the unit tonight she told me that she
wouldnt be, she then said that she was getting another phone call and hung up. The writer called
Bob (on-call) and then DHS A/H who asked that we call back if she returns or to call in the
morning if she doesnt. Roslyn
Tuesday
Jane had still not returned to the unit when the writer arrived this morning for shift. The writer
attempted to call DHS A/H but kept getting disconnected even before the call was answered.
Shavonne called Jane at 4:10pm to do a safety check. Jane appeared to be in a good spot on the
phone and indicated that she was not in ________ and would be returning tonight if she could
get a train. Calls were made to On-call Bob, DHS A/H who said that she would read her file and
check with her team leader about a return to placement warrant and the writer also called
________ Police to do a missing persons as requested by both Bob and DHS.
The writer spoke to Constable N Smith who took Janes number and said he would call back
after discussions with his superior. Constable Smith called back at 4:40 saying that he had
spoken to Jane and she had given him the same info as to Shavonne about coming back if a train
is available, and at this stage feels a missing person is unwarranted. Roslyn

End of Resi Notes transcripts

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Appendix B: Summary of the pedagogical framework of my proposed holistic and integral

Dynamic Healing and Educational Centres


- holistic & creative care re-building lives _________________________________
As stated in my submission, alternative educational programs and facilities exist for at risk and
disengaged young people. Many have been around for many years and are led by hard-working, creative
and passionate teachers.
I am not an academic expert in this field, but I am a trained teacher who has worked in alternative
curriculum programs in two mainstream schools for such students, so I have a reasonable knowledge of
the crucial pedagogical issues involved.
A format for the DHECs that I would consider appropriate and most likely to succeed is one that
considers the practical learning deficits and difficulties that the students have such as:

Very short attention spans (around 10-15 mins; 30 mins at max)


Inability to sit still/fidgety/nervous/uncomfortable in a formal, educational environment
Lack of self confidence in reading, writing, research or any academic-type activities (or
being essentially illiterate or semi-literate at best)
General lack of respect or outright hostility towards authority figures including
teachers/carers

The hardcore children we are talking about of course also have the added issue of drug and nicotine
dependency and the resultant behavioural issues these addictions cause.
The DHECs would especially be for children from Out of Home Care, however, any other similar child
could be required to compulsorily attend including those who currently attend mainstream schools but
who also have serious behavioural issues and are highly disruptive.
The centres would be state of the art and provide the best for the teachers and students to enable to
rehabilitation, reformation, healing and education to occur. I deliberately placed the word education last
in the previous sentence, as education will not occur while these kids are on drugs, absconding or being
violent and while the basic psychological/psychiatric and physiological manifestations of their trauma and
PTSD is not tackled properly. Only when healing starts and will these children be able to engage in a
relatively creative and peaceful manner with the wider community including schools. For example, the
teenage boy mentioned in my main submission who defecates in his pants, does not just do this at night,
but at all times. That is, he can come back to the unit at say 4 pm from being out somewhere and he will
smell of shit and have fresh shit in his undies.
Adequately supporting a child like this would be a challenge while trying to of course actually heal (or at
least partly so) the underlying emotional issue so the physiological manifestation of his trauma can be
ended.

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Dr West, Philip Alan. Submission to the Royal Commission into Institutional Responses to Child Sexual Abuse.
Out of Home (Residential) care as State-Sanctioned Abuse and Neglect.

Lets say the 14-yr-old child of the Minister for Community Services or a senior DHS manager witnessed
the death of the other parent in a car accident or a random act of violence in the street and they manifested
their trauma though severe stammering or bed wetting or defecating in their pants. I am sure that the
Minister or DHS Manager as a caring, loving, responsible parents, would do everything they could and
and spend whatever was required to help their child.
The most important word in relation to the HDECs is the word holistic which is found in motto:
holistic care to rebuild lives. The centres will not be schools. Educational outcomes will be just one
dimension.
The facilities:
The facilities would be built in consideration of the very special educational requirements of such
children and of the specific required outcomes.
The following is an abridged list of the hoped for outcomes (many other points could be added to this
list!)

Stopping their drug and tobacco dependency


Healing their trauma and PTSD so they can:
o Start to love themselves and grow self-respect and confidence
o Be healed of physiological manifestations of the trauma such as bed wetting, stammering
or defecating in their pants
o Start to understand and subsequently control their anger, hostility, aggression and verbal
and physical violence.
o Start to learn and develop educationally
o Start to be able to relate in a humane way to others and to show others respect and to feel
empathy.
o Star to understand the meaning of the word responsibility. They already know all about
their rights which they can tell you in no uncertain terms at any time.
o Rebuild their lives

We must provide these children with the absolute best, not the 3rd and 4th best. Currently, most alternative
educational facilities are found on a old bit of spare land somewhere with a few old portables thrown
down with a couple of tin sheds or are in a few old portables down the back in an existing mainstream
school campus.
The facilities would contain a sports hall and gym with weights room, an art, music and drama centre
(incorporating art and music healing therapies as well as a performing arts stage), oval, small indoor
heated swimming pool, a BMX track, a healing forest for solitary reflection, emotional release and quiet
time, an Outdoor Ed area with climbing ropes, obstacles and rock climbing wall and a cookery room
amongst the usual classrooms and library and resource centre.
See the next page for an illustration of a sample DHEC.

Preliminary facilities plan may look as follows:

1: Street art/graffiti walls

Bicycle Shed

Driver Ed/bicycle track

2: Indoor swimming
pool (25 mtr)

Main buildings/classrooms

Sports Hall

2
Gym/Weights room
Art/Music/drama/performing arts stage
including small recording studio

Healing
Forest

Sports Oval with


running track

Outdoor Ed
area
MBX Track

CHILD

Flow Chart showing the structure of


the Dynamic Healing and Educational
Centres

Attending Mainstream Education

Attending an alternative education


facility on a full-time or near to fulltime basis.

None or only minor and manageable


behavioral problems

Not attending Mainstream Education


or any schooling (or only
piecemeal/very occasional attendance
at an alternative program) and is
generally disruptive, abusive or nonengaging when attends, is a regular
drug abuser and/or junior criminal

Compulsory FULL TIME attendance at a


Continues with mainstream or fulltime alternative schooling

Dynamic Healing & Education Centre


(Stream One: Community)

Completes VCE/VET/VCAL (or other


Australian equivalents such as HSC in
NSW), pre-apprenticeship etc

If reforms, starts to rehabilitate, gets


off drugs and is truly engaged in the
integral healing, education and
personal development programs.

Further study or work


Continues at the DHEC or perhaps
eventually engages in mainstream
school, tech college, TAFE etc
Child develops into a basically welladjusted, decent member of our
larger community and society with
the ability to relate confidently to
others, to love and care for children
adequately and with the basic skills
and knowledge to contribute
positively to our community, society
and economy.

If disruptive and/or violent


and/or still taking drugs,
regularly absconding from
home/out of home care,
engaging in crime

Compulsory internment under the


Mental Health Act in a
Dynamic Healing and Education Centre
(Stream Two: secure)
Min of three months

If starts on path to recovery from drug addiction, violent behaviors etc can
then be returned to DHEC Stream One. If rehabilitation, recovery and
educational engagement is inadequate, internment in Stream Two continues

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