A damning report on the neglect and abuse of people with a disability has used the choking death of Canberra woman Stephanie Fry to warn of the dangers of staff turnover and the increasing reliance on casual support workers.
The Senate's community affairs committee inquiry has heard harrowing evidence about violence and abuse in residential care and institutions since it began in February.
It released its final report on Wednesday, calling for a royal commission to better investigate the types of "cruel" and "shocking" examples put before the inquiry.
On Thursday, Social Services Minister Christian Porter said the government would consider the committee's 30 recommendations, which also include a national watchdog to investigate abuse and better screening for people employed in the sector.
"Violence, abuse and neglect of people with disability is abhorrent regardless of the situation, scale or location in which they occur," a spokesman for Mr Porter said.
"The committee's inquiry and report shines a much needed light on this important problem.
"The Commonwealth will carefully consider the inquiry's findings and recommendations before deciding whether there is a need for further investigative processes."
The committee cited the death of Ms Fry, a resident of a Disability ACT group home in Stirling, as it highlighted the dangers of relying too heavily on casual workers in unfamiliar environments.
The circumstances of that case were uncovered during a Fairfax Media investigation, which was published last week, showing Ms Fry had been fed bread and left unsupervised by unfamiliar casual workers who had failed to heed stark choking warnings contained on her file.
The inquiry report read:
"Evidence presented to the inquiry indicated that the casualisation of the disability workforce, and the likelihood it will increase under the NDIS, is a key contributor to abuse and neglect of people with disability."
That echoes the views of local disability advocates, such as Advocacy for Inclusion chief executive officer Christina Ryan, who have warned it is crucial to address systemic workforce issues before the NDIS transition is complete.
Greens senator Rachel Siewert, who chaired the committee, said she was confident that when the government read the detail of the report, it would see the need for a royal commission.
"I think we make a very compelling argument for these changes," she said.
The government's cautious response comes as disability advocates backed the call for a royal commission.
Therese Sands, co-chief executive of People with Disability Australia, said the Senate committee's recommendation of a royal commission was warranted.
"Enough is enough. This is our nation's opportunity to show those that have been failed by the system that they deserve justice," she said.
"The significant level of violence perpetrated against people with disability in institutional and residential settings warrants the establishment of a royal commission and we wholeheartedly support the recommendation made in the report."
People with Disability Australia and Australian Cross Disability Alliance held a memorial on Wednesday to remember those with disability who lost their lives to violence, abuse and neglect.
Other disability advocates welcomed the call for tougher standards on staff working with the country's most vulnerable people, but warned the National Disability Insurance Scheme would not solve training requirements.
The inquiry heard evidence from people with disabilities and staff that poor training was leading to deaths, injuries and abuse.
The inquiry, which focused on people in residential settings, was told that the proportion of casual disability workers was likely to increase under the NDIS.
"There is also a risk … that the casualisation of the workforce will increase – and we know that there is an association between high workforce turnover, in the context of workforce shortages, and the prevalence of abuse and neglect," National Disability Services chief executive Ken Baker told the inquiry.
Liz Kelly, a management consultant and mother of a child with a disability, welcomed the recommendation for a national staff registration scheme and independent oversight of workers but said the sector needed more funding for staff training and support.
"It's great to see these recommendations ahead of the full NDIS roll out but where is the money to support them going to come from?" she said.
"There has to be greater investment in staff training. Providers are saying loudly and clearly that the funding amounts set under the NDIS will not cover staff training and development."
Chief executive of Northcott Disability Services Kerry Stubbs said improved oversight and a mandatory reporting scheme recommended by the committee would help to prevent abuse and neglect.
"While we understand the desire to hold a royal commission to further investigate this issue we hope it doesn't slow up the implementation of the excellent recommendations that have been made by the committee," she said.