A respite care home which failed to provide a secure environment for an 11-year-old autistic boy, who escaped and drowned in a duck pond, has been found at fault by the New Zealand health watchdog.
In a decision released today by the Deputy Health and Disabilities Commissioner Tania Thomas, it was found staff at Auckland-based Spectrum Care Trust were aware of Julian Stacey's propensity to escape, but failed to take "sufficient preventative action" to ensure his safety.
The boy, whose name was left out of the report but released to media by his mother, died in 2010 when his body was discovered in a duck pond near the facility.
It was reported to police that he had only been missing for about 15 minutes, when he vanished from a playroom in the house and was believed to have left through a back gate.
Julian's mother, Tash, released the boy's name to Radio New Zealand because she wanted lessons to be learnt from the tragedy.
In Thomas' findings, she said most of the locks and exit points were rechecked by staff after they returned with the children from an outing earlier that day.
But the back gate lock was not physically checked.
The gates required a keypad code to be entered in to unlock from the inside, however the gate would not lock properly unless it was pulled tightly shut. The gate however, could be opened without having to unlock it from the outside.
Children playing in the park at the rear of the facility had been known to open the gate in the past to retrieve balls.
Julian was diagnosed with autism and an intellectual impairment. He had the cognitive functioning of a one- to two-year-old child, and a number of behavioural needs, including a tendency to escape.
This was documented in a Spectrum Care "crisis plan", where his escape risk was categorised as "catastrophic".
"[Julian] will be watching the door (front door), he may be roaming outside and attempting to get under gaps in the fences. If he absconders [sic] he may do it when staff are preoccupied. He is quick & can get away to the main road.
"[Julian] has no road safety sense and enters strangers [sic] houses, he also will go with strangers in the car," the plan said.
In 2008 he escaped four times, and then twice in 2009. Most times he escaped through the front gate, which was sometimes left open by visiting parents dropping off or picking up children.
Thomas said while best practice care was not followed, the tragedy was not born out of complacency.
"In my view, there was not just one issue leading to a problem with Master A's [Julian's] safety but a series of inadequate or incomplete strategies.
"In light of Master A's known propensity to abscond, the layering together of a number of factors resulted in an accumulation of defects which point to a pattern of suboptimal provision of services to Master A."
Since his death, Spectrum had already made a number of security changes, including installing buzzers which sounded if an exit point was left open.
She recommended Spectrum Care carry out a full review of its progress made in security in the wake of the boy's death. Copies of the report would also be sent to the coroner and police.