On 19 December 2025 the County Court of Victoria ordered that this notice be published on the website of Amicus Community Services Ltd 

On 6 May 2021, Joanne ‘Jo’ DWYER (the deceased) was in the care of Amicus Community Services Ltd, a provider of disability services. The deceased had several disabilities, including: 

• Albrights Hereditary Osteodystrophy Syndrome;

• Refractory epilepsy-Lennox Gestalt Syndrome;

• Intellectual disability moderate to severe; and

• Autism with high sensory modulation disorder and profound communication disability with aphasia and perseveration.

Because of her epilepsy, the deceased experienced frequent seizures. 

The deceased received full-time supported independent living services from Amicus and had so for approximately eight years. One of the services she received was ‘active overnight monitoring’. 

At 1.18am on 6 May 2021, the deceased suffered a seizure and fell out of bed. She died at 1.42am. Her epi-mat sounded loudly for 30 seconds. No visual check was made of the deceased until 9.06am. The system in place governing how and when a supported independent living worker was to provide ‘active overnight monitoring’ for the deceased was not as safe as reasonably practicable. 

On 19 September 2023, Amicus was charged with two offences against the Occupational Health and Safety Act 2004. The first charge alleged that if the deceased experienced a seizure there was a risk to the deceased of death or serious injury as a result of obstructed airways, coming into contact with nearby hazards, hypoxia or uncontrolled seizures leading to death. 

In order to control that risk it was charged that Amicus should have ensured that the deceased was regularly and directly observed between the hours of 12am and 6am by setting monitoring requirements in accordance with the Amicus Community Support Worker Manual being: 

• requiring employees to conduct a close physical check of the deceased, by attending at the deceased’s bedside at least every two hours (and when the seizure alarm mat sounds) and visually observing the deceased over a period of 1-2 minutes to ensure the deceased’s colour can be reliably observed and that her breathing (rise of chest, sound of breath) can be reliably detected;

• providing employees with information, instruction and training as to directly observing the deceased at least every 2 hours by attending her bedside;

• enforcing the system with an adequate checklist for observations made and when those observations were made; and

• employees being required to sign off that they have read and understood the monitoring requirements prior to commencing their first unsupervised active overnight shift.

The second charge alleged that Amicus failed, without reasonable excuse, to notify the Victorian WorkCover Authority (VWA) immediately after becoming aware that an incident had occurred at a workplace under its management and control, being the death of their client. 

On 6 May 2021, Amicus notified Victoria Police of the incident. On 7 May 2021, Amicus notified the NDIS Quality and Safeguards Commission of the incident. On 21 January 2022, following contact by investigators for the VWA, Amicus notified the VWA of the incident. 

Amicus pleaded guilty to both charges. 

On 19 December 2025, the County Court of Victoria convicted and fined Amicus $370,000 and ordered it to publicise the offence and penalty imposed in the form of this notice.