A profoundly disabled woman choked to death in a government-run group home when ill-prepared, confused casual staff failed to heed warnings that she had a dangerous tendency to gorge food.
The case of Stephanie June Fry exposed the same systemic failings of the disability-care system that were highlighted by a judge investigating three preventable deaths 14 years ago: high staff turnover, inadequate worker induction processes, and a reliance on unsupervised casual staff unfamiliar with residents' needs.
The ACT government pledged to improve their practices in 2001, and made a similar commitment to the coroner after Ms Fry's death in 2011.
But four years on, disability sources say serious staffing problems and mismanagement continue to place carers in perilous situations.
"We've gotten to a point where they are asking good people to do their job at such a dangerous level that it's an accident waiting to happen," one former support worker said.
On the morning of August 9, 2011, Ms Fry, 52, awoke at the government-run Hardey Group House in Stirling, where she had spent the past 20 years.
The house had serious staffing problems. The supervisor was absent and three casual workers from labour-hire firms were brought in to cover.
Two of the casuals had never worked at Hardey before, an apparent contradiction of the government's policy of preferring staffing continuity at its group homes.
None of the staff were at supervisor level, and one said they weren't even shown around the home before their shift began.
Inexperienced casuals are told to turn up 30 minutes early to learn about each resident's needs.
But the casuals either did not read Ms Fry's file or paid no heed to the stark warnings it contained beneath the heading "keeping Stephanie safe".
"All staff must be aware of their obligation of their role to fully supervise Stephanie during all eating. i.e. Staff must maintain visual contact at all times when food is present," her individual plan said.
"If Stephanie gets the chance she will gorge until she chokes and dies. Stephanie is not to be given bread."
Ms Fry had been resuscitated on two previous occasions due to choking incidents.
The warnings were missing from a separate folder, named the "casual folder", designed to quickly brief casuals about the house and residents.
The new staff also failed to complete a handover checklist, which would have ensured they had read the choking alert.
Hours later, they began making toasted sandwiches for lunch. The only casual with any experience at Hardey, about 10 shifts, left the home.
The remaining staff were confused: no one knew who was making what meal for which resident.
One casual told an external consultant's investigation into Ms Fry's death: "I had no idea what was going on because there was so much food everywhere and plates, and I wasn't getting clear answers either."
The same worker remembers seeing Ms Fry with a mouth stuffed full of sandwich, walking away from the kitchen and out of sight of the workers.
"I said it out loud, I was like 'she's got a bit of food crammed in her mouth,' and just said it to whoever was there basically because everyone was there. Then [another staff member] was like 'she sometimes does that.' "
Two minutes later, a scream was heard from the bathroom. Ms Fry's body had been found, and she was turning blue as she choked on the bread. She was rushed to hospital but it was too late to save her, despite the best efforts of the workers who administered first aid.
An ongoing Fairfax Media investigation, which raised serious concerns in August about the government's failure to refer abuse claims to police, has brought Ms Fry's case to light for the first time.
Court documents show Ms Fry's family had previously warned the government about the home's high staff turnover, saying it was causing communication breakdowns and distress to Ms Fry.
The government never spoke of the death publicly, instead paying a workplace investigations consultancy to look into the case.
The circumstances of the death were kept under wraps even when Fairfax Media questioned the government directly in 2012 about whether it was caused by staff error.
The Community Services Directorate now says it did not make the circumstances of the death public because it does not "make public statements on individual clients or that relate to an individual client".
Ms Fry's death was referred to the coroner, who found the cause of death had already been established and decided not to hold an inquest. The coroner found no issues of public safety arose.
It is understood Ms Fry's family did not want the coroner to hold a hearing into the death. It is also understood the coroner wrote to Disability Minister Joy Burch with the support of Ms Fry's family about the case.
Fifteen years ago, three similarly preventable deaths took place in government-run group homes.
They sparked a major inquiry into the disability sector by former ACT Supreme Court Justice John Gallop.
Justice Gallop's wide-ranging 2001 report told the government its handover procedures were "inadequate" and found its induction process of 30 minutes for new staff was not long enough.
He warned against a reliance on unfamiliar casual staff and urged the government to create a "strategy to attract and retain care workers to the disability sector".
"There is an unacceptably high usage and turnover of casual staff, despite the [disability program's] claim that casual staff are retained to work with the same clients as much as possible," Justice Gallop wrote.
"Key workers are changed too frequently. This results in lack of familiarity with clients and key workers are accordingly ineffectual ... This further adversely impacts on their ability to properly consider and implement client's individual plans."
The government provided a list of changes it had made to the disability system to Coroner Beth Campbell as she considered whether to hold a hearing into Ms Fry's death.
The changes included better shift planning, an improved staffing ratio to support unfamiliar staff, improved inductions, better training on choking risks, reminding staff to read alerts about residents, and maximising information and support for newer staff.
A Community Services Directorate spokesman said the government had apologised for the death and offered its condolences to her family.
"Ms Fry's death is not indicative of systemic failings but does represent a grave error for which we apologise," he said.
"We have made significant changes to the way we ensure staff have the information they need to properly support people with disability in group homes."
"For example we try to ensure that, as far as possible, staff familiar with clients and their needs are allocated the shifts to work with them."
The spokesman said they routinely communicate with casual agencies and review their performance every year, and have a more consistent approach to maintaining resident information across all homes, making it easier for new workers to learn their needs quickly.
The directorate also puts permanent staff through a rigorous six-week induction process, the spokesman said, followed by 20 observational shifts in a home and ongoing mandatory training. Casual and contract staff were expected to undergo the same.
Yet disability workers say the staffing problems identified in Ms Fry's death still exist.
Alistair Davidson, an experienced support worker who recently left Disability ACT, said rostered hours had been reduced to a "dangerous level" by the time he left.
He said unfamiliar staff were "absolutely" still being thrown into complex group home environments without adequate preparation.
"Anyone can tell that the workplace is not going well, yet there seems to be this head-in-the-sand approach to it all," he said.
"The talent pool has reduced even since Stephanie's death, we have more people who still have so little experience still being thrown into the deep end."
Another experienced support worker, Bernie Roveta, said he noticed little change from the time of Ms Fry's death to when he left his job in 2013.
He said Disability ACT were still desperate for staff and that training was not translating into competency in many cases.
"I'd like to know what they are talking about when they say they changed everything in 2012," he said.
The government will have transitioned out of group homes by June 2017, in line with the National Disability Insurance Scheme.