An Auckland-based trust providing respite care for children has been found at fault after an 11-year-old autistic boy escaped and drowned in a nearby pond.
The boy, who was also intellectually impaired and had been spending time at the Spectrum Care centre for four years, died in 2010 after he escaped through a backyard gate.
In a decision released on Wednesday, Deputy Health and Disability Commissioner Tania Thomas ruled Spectrum breached its obligation to provide the boy with reasonable care.
There was a series of inadequate or incomplete strategies, she said.
- Spectrum focused on the front door when trying to prevent the boy absconding.
- Backyard gates had locks only on the inside and could be opened from the outside.
- Spectrum failed to reliably record the gates had been checked and were securely shut.
- The level of supervision was reduced because of the time of day.
- There was also a failure to ensure the child's crisis plan was updated.
Ms Thomas' report revealed staff had been told to watch him closely when he was outside.
The previous year he had tried to escape the centre three times, and had successfully escaped another two times.
The backyard gate had appeared to be closed from a distance, but was not physically checked before he was allowed to play in the backyard.
A staff member noticed he was missing and the gate was open.
It was estimated he was missing for 15 minutes before his body was found in the duck pond.
The gate was found to stick and needed extra force to close it properly. While it could be locked from the inside, it could still be opened from the outside.
Spectrum said a member of the public may have entered the gate - perhaps children retrieving their balls - and not closed it properly.
Spectrum said it had made changes to prevent a similar incident.