Executive Summary

Confidential Investigation Report

Bendigo Special Developmental School

18 March 2016

Introduction
1. This Executive Summary has been prepared at the request of the Department of
Education and Training (DET).
2. The Executive Summary sets out the key information and findings contained in the
Confidential Investigation Reports provided by Justitia to Mr Bruce Armstrong, Acting
Deputy Secretary, Regional Services Group, DET on 10 December 2015 (the Expedited
Report) and 29 January 2016 (the Report).
3. Justitia is an employment and labour relations law firm that regularly conducts workplace
investigations into allegations of misconduct.

Investigation process
4. Justitia was engaged by the DET on 20 October 2015 to conduct an investigation into
issues of concern at Bendigo Special Developmental School (Bendigo SDS).
5. Justitia conducted the investigation during October 2015 January 2016 and provided its
reports to the DET on 10 December 2015 and 29 January 2016. The investigation process
included two main phases.
6. In Phase 1, Justitia invited willing participants (i.e. complainants), who wished to report
issues of concern, to be interviewed. Justitia spoke to all 13 complainants who requested
to be interviewed as part of Phase 1. The complainant group included current and former
parents, current and former Bendigo SDS employees, disability advocates and community
members.
7. Other interested parties contacted Justitia during Phase 1 to request an interview so as to
report their confidence in Bendigo SDS. These other interested parties included current
and former parents and current Bendigo SDS employees. Justitia met with five of these
individuals and others submitted written statements by email to Justitia.
8. In consultation with the complainants, Justitia prepared a list of allegations against
current members of Bendigo SDS staff. This consultation period involved obtaining the
consent of the complainants to have their allegations put to respondents for a response as
part of Phase 2 of the investigation. The complainants were advised that this process
would mean that they would be identified to the respondents as the relevant complainant
in respect of their allegations. Three complainants did not provide their consent to the
allegations entering Phase 2 of the investigation. These complainants were advised that,
as a result, no finding would be made in respect of any allegations they made.
9. After this consultation period, there were 40 allegations in the list of allegations. The
allegations were against 12 respondents. All 12 respondents were current members of
Bendigo SDS staff.

10. Three allegations (the Clothesline Yard Allegations) were addressed as part of an
expedited investigation at the request of DET. The allegations that were the subject of the
expedited investigation were not against a particular respondent(s). These allegations
were reported on in an earlier Expedited Report.
11. In addition to the allegations, Justitia drafted five lines of inquiry to be put to the
Principal of Bendigo SDS, Ms Julie Hommelhoff, in relation to general areas of concern
that had been raised by DET and by the complainant group. Other staff members and
parents who were interviewed as part of the investigation were asked to provide
information regarding these lines of inquiry.
12. In total, therefore, Justitia investigated 43 allegations and five lines of inquiry.
13. In Phase 2 of the investigation, Justitia put the allegations to the respondents in writing
and then interviewed the respondents to obtain their responses to the allegations. In
addition to the 12 respondents, Justitia interviewed eight witnesses as part of Phase 2.
14. At the completion of Phase 2, Justitia prepared a Report of its findings for Mr Armstrong.
The Report was provided to Mr Armstrong on 29 January 2016.

Key allegations and lines of inquiry

15. The list of allegations and lines of inquiry included the following key concerns:
a. There were (or are) structures at Bendigo SDS that are used to restrain or
seclude students. This included allegations that:
i. the outdoor playground at Bendigo SDS includes a number of smaller
play spaces that are fenced off within the main playground (Enclosed
Spaces);
ii. in or around 2007, there was a safe room known as the wooden
cubby house purpose built at Bendigo SDS, which was used to seclude
a student (Cubby House);
iii. there are enclosures in classrooms at Bendigo SDS to seclude students,
including:
1. a pen used in Room 6 in 2015; and
2. a pen used in Room 17 in 2014,
(Classroom Pens); and
iv. there is an enclosure made out of pool fencing with a lockable gate in
the courtyard outside Room 5 at Bendigo SDS that was used to seclude
a student (Room 5 Courtyard),
(Structures Allegations).
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b.

The student for whom the Cubby House was purpose-built at Bendigo SDS
would sometimes be restrained by a number of male teachers before being
escorted to the Cubby House. The student would remain in the Cubby House
for lengthy periods without supervision (Cubby House Restraint and
Supervision);

c.

On 20 October 2015, at 10:32am, a student was locked up in the clothesline

yard outside the kitchen area at Bendigo SDS (Clothesline Yard
Allegations). The Clothesline Yard Allegations were the subject of the
Expedited Report;

d.

Staff at Bendigo SDS used pressure points to restrain students:

i. in 2009, in Room 5, two different ESS staff members, on separate
occasions, picked up a student by using pressure points behind his
ears; and
ii. in mid-October 2014, an ESS staff member put thumbs on the pressure
points under a students armpits to make the student stand up,
(Pressure Points Allegations);

e.

In 2007 or 2008 and again in 2010, staff at Bendigo SDS received training in
martial arts techniques to move and restrain students (Training Allegations);

f.

Sometime in 2009, at approximately 3:00pm, a parent arrived at school to pick

up their child. The student was outside the classroom and crying. Inside the
classroom, the teacher took a student to the sink, grabbed a water bottle and
squirted the student in the face and repeatedly said, stop crying. The
classroom door was locked and the teacher would not let the parent and
student leave until the student stopped crying (Water Bottle Allegation);

g.

In 2012, a student was subjected to seclusion by being placed in a pen (Pen

Allegation);

h.

In the period from mid-2013 until mid-2014, a teacher taught a female student
who self-abused and would drop to the floor. The teacher sometimes withheld
the students lunch or made the student walk out of class (Lunch Allegation);

i.

In 2013, a teacher left a student at a local shopping centre during a community

access visit. Ms Hommelhoff directed the teacher to do so because the student
was street smart and will find his way home (Shopping Centre Allegation);

j.

In 2013, a teacher drove a students head into the concrete causing the
students head to split open (Student Assault Allegation 1);

k.

In 2014, a teacher hit a student when the student left his chair (Student
Assault Allegation 2);
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l.

In 2010, Bendigo SDS retained a students Level 4 PSD funding after it was
notified that the student would not be returning to Bendigo SDS (Funding
Allegations); and

m.

Staff at Bendigo SDS did not make attempts to monitor or adequately explain
bruising on students upper arms and backs:
i. On three occasions in the period 2011-2012 a parent met with Ms
Hommelhoff and the students teachers to discuss bruising on the
students upper arms and back. Ms Hommelhoff and the two teachers
were dismissive of the parents concerns; and
ii. In March 2009 and over subsequent months, a parent asked a students
teacher about bruising on the students upper arms. The teacher did not
make attempts to document the bruising or monitor the cause of the
bruising,
(Bruising Allegations).

16. In addition to the above, a number of allegations and lines of inquiry addressed concerns
regarding communication and information-sharing between Bendigo SDS and parents.
These allegations included that:
a.

two versions of an Intellectual Assessment Report were prepared for a student.

The version of the report provided to the students parents contained different
information to that in the report provided to Bendigo SDS;

b.

when a student ceased enrolment at Bendigo SDS in 2015, the parent asked for
the students file. Ms Hommelhoff told the parent to make an FOI request;

c.

Ms Hommelhoff did not inform a parent about an alleged incident reported to

her with respect to an ESS staff member applying a pressure point technique
to a student;

d.

on 3 December 2010, a parent received a placement letter for their child for
2011. The parent had advised the school and the Department that the student
would not be returning to school. At the time, the student had not attended
school for 18 months;

e.

parents access to Bendigo SDS is restricted because parents are required to

drop their children at the school gate / bus bay, rather than accompanying
students to class; and

f.

information included in communication diaries between parents and teachers

is not always fulsome or useful,
(Communication Allegations).

Investigation Findings
17. Justitia made findings of fact based on the balance of probabilities.
18. An allegation was found to be substantiated if there was sufficient evidence to
substantiate it. If there was insufficient evidence to substantiate an allegation, or if the
evidence did not support the allegation, the allegation was found to be not substantiated.
In circumstances where there was evidence to substantiate part but not all of the
allegation, the finding was that the allegation was partially substantiated.
19. Of the 43 allegations, 20 were made directly against Ms Hommelhoff by the
complainants. Of the 20 allegations against Ms Hommelhoff, Justitia found that:
a. Three of the 20 allegations against Ms Hommelhoff were substantiated. In
summary, the substantiated allegations included:
i. the Classroom Pens Allegation; and
ii. the Pen Allegation
(together these allegations were the subject of three direct allegations
against Ms Hommelhoff).
b. Eleven of the 20 allegations against Ms Hommelhoff were not substantiated.
In summary, the allegations that were not substantiated included:
i. an allegation that Ms Hommelhoff had advised a teacher that a ESS was
trained in the technique of using pressure points and entitled to use that
technique;
ii. an allegation that Ms Hommelhoff, in relation to the student who was
the subject of the Shopping Centre Allegation, stated that the student
was street smart and will find his way home;
iii. an allegation that Ms Hommelhoff had not investigated the incident that
was the subject of Student Assault Allegation 1;
iv. an allegation that Ms Hommelhoff did not follow up with the relevant
ESS after that ESS reported the use of pressure points on a student;
v. an allegation that Ms Hommelhoff escorted a student to the students
mothers car such that the student had no weight on his feet and could
not use his arms;
vi. an allegation that Ms Hommelhoff was dismissive of a parents
concerns in relation to bruising on a student (see: Bruising Allegations);

vii. an allegation that Ms Hommelhoff did not make further inquiries with a
parent in relation to that parents concerns their child being manhandled
at Bendigo SDS;
viii. an allegation that a student was placed in locked secluded areas at
Bendigo SDS and escorted to these areas by an adult who placed the
students arm behind his back;
ix. an allegation that when a student transferred to another school, Ms
Hommelhoff did not transfer the students complete records to the new
school;
x. an allegation that Ms Hommelhoff recorded a discussion with a parent
in her office; and
xi. an allegation that a student was inappropriately placed on a two-wheel
bicycle without the parents consent.
c. Six of the 20 allegations against Ms Hommelhoff were partially substantiated.
In summary, the substantiated elements of the partially substantiated
allegations included the following:
i. it was substantiated that two training sessions were conducted at
Bendigo SDS by the providers named by the relevant complainant in
relation to the Training Allegations;
ii. it was substantiated that Ms Hommelhoff did not inform a parent about
an alleged incident involving the use of a pressure point technique on
their child (see: Communication Allegations);
iii. it was substantiated that Ms Hommelhoff told a parent to make an FOI
request in respect of any incident reports (see: Communications
Allegations);
iv. it was substantiated that a parent received a different intellectual
assessment report to that provided to Bendigo SDS in relation to their
child (see: Communications Allegations);
v. it was substantiated that Bendigo SDS retained Level 4 PSD funding for
a student in 2010 (see: Funding Allegations); and
vi. it was substantiated that a parent received a placement letter for their
child for 2011 (see: Communications Allegations).
20. Of the remaining 23 allegations:
a. Five allegations were substantiated. In summary, the allegations that were
substantiated included:
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i. the Pen Allegation (this allegation was made against Ms Hommelhoff

and another teacher);
ii. an allegation that a teacher told a parent that the parent would have to
report certain personal information to Ms Hommelhoff;
iii. an allegation that a teacher provided a parent with documentation and
made a comment to the effect that Bendigo SDS could help the parent
by accessing services through the parents child; and
iv. two of the Clothesline Yard Allegations, namely that a child was
secluded in the Clothesline Yard as alleged without supervision.
b. Fifteen allegations were not substantiated. In summary, the allegations that
were not substantiated included:
i. Student Assault Allegation 2;
ii. two allegations that teachers (in addition to Ms Hommelhoff) were
dismissive of a parents concerns about bruising on their child (see:
Bruising Allegations);
iii. the three separate Pressure Points Allegations, namely the two
allegations against the ESSs regarding conduct in Room 5 in 2009 and
the allegation regarding the use of pressure points in 2014;
iv. an allegation that a teacher reached an agreement with parents
regarding a change to a Behaviour Management Plan and failed to
communicate that change to other staff members;
v. an allegation that a teacher would not allow a student to have her piano
keyboard in the classroom;
vi. an allegation that a teacher did not follow up on a parents concerns
about their childs behaviour at home after offering to speak to an OT at
Bendigo SDS about it and report back to the parent;
vii. an allegation that a student was placed in an unspecified secluded area
in March-April 2014;
viii. an allegation that a teacher did not return a students communication
diary when the student ceased enrolment at Bendigo SDS;
ix. an allegation that a teacher did not provide adequate information to a
parent about incidents involving the parents child while he was
enrolled at Bendigo SDS;
x. an allegation that a teacher did not attempt to document bruising on a
student or monitor the cause of the bruising (see: Bruising Allegations);
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xi. Student Assault Allegation 1; and

xii. an allegation that the clothesline yard was not appropriate space for the
relevant student to be (this was the third allegation in the allegations
together described as the Clothesline Yard Allegations).
c. Three of the allegations were partially substantiated. In summary, the
substantiated elements of the partially substantiated allegations included the
following:
i. it was substantiated that a teacher sometimes asked a student to walk
out of the class with an ESS when the students behaviours escalated
and that sometimes this meant that the students lunch would be
delayed (see: Lunch Allegation);
ii. it was substantiated that a teacher may have sprayed mist on a student
and that the door to the teachers classroom was locked from the inside
(see: Water Bottle Allegation); and
iii. it was substantiated that a teacher left a student at The Market Place
during a community access visit on 24 October 2014 (see: Shopping
Centre Allegation).
21. Justitia is satisfied that there is at present no reasonably foreseeable risk of injury or
inappropriate treatment to current students at Bendigo SDS in respect of the concerns that
were the subject of the investigation. Justitia bases this conclusion on the findings in
relation to the 43 allegations and the information gathered in respect of the five lines of
inquiry and on the assumption that its recommendations with respect to the Clothesline
Yard Allegations are carried out.
22. The Reports findings include that:
23. In respect of the Structures Allegations, Justitia found that the Enclosed Spaces, the
Cubby House, the Classroom Pens, and the Room 5 Courtyard either existed or currently
exist at Bendigo SDS.
24. Justitia was provided with evidence to support a conclusion that the use of Enclosed
Spaces, Classroom Pens, and the Room 5 structure at Bendigo SDS is appropriate. Justitia
was provided with information to the effect that:
a. The Enclosed Spaces have an important role to play in keeping Bendigo SDS
students safe. This is because (among other things) some students could
abscond from the school grounds if the outdoor play areas were not fenced;
b. The Classroom Pens resemble playpens. The Classroom Pens were required in
Room 6 in 2015 and in Room 17 in 2014, in order to ensure the safety of a
student who experienced seizures. The student used the Classroom Pen as a
safe place to lie down and recover (so that visually impaired students did not
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trip on the student, and / or so that the student was separated, during recovery,
from other students that may display aggressive behaviours such as biting or
scratching); and
c. The Room 5 Courtyard was enclosed to ensure that a former student, who
regularly absconded from school, could play safely outdoors. The Room 5
Courtyard remains enclosed.
25. In respect of the Cubby House, Justitia found that in or around 2007, prior to Ms
Hommelhoffs employment at Bendigo SDS as Principal, the Cubby House was purpose
built for a particular student whose behaviour could become violent and aggressive and
pose a risk to staff and other students. When the students behaviour deteriorated to this
stage, the student was secluded in the Cubby House for time out in accordance with his
Behaviour Management Plan. The Cubby House could be locked from the outside.
26. In respect of the Cubby House Restraint and Supervision Allegation at 15(b) Justitia
found evidence to support a finding that more than two staff members were on occasion
required to escort the student to the Cubby House. This practice was in breach of the
students Behaviour Management Plan, which stated that the student may be escorted to
the Cubby House by two staff members.
27. Justitia found that the relevant student was supervised while the student was in the Cubby
House, either by a teacher who was directly observing the student from outside the Cubby
House or via a camera that allowed the students teacher to monitor the student from the
classroom.
28. The Cubby House was developed in consultation with the Departments OHS
Representatives and in accordance with the students Behaviour Management Plan, which
was signed by the students parent. In or around 2010, the Cubby House was dismantled
and no similar structures currently exist at Bendigo SDS.
29. In respect of the Clothesline Yard Allegations:
a. it was substantiated that on 20 October 2015, due to the error of an ESS, a
student was locked in the clothesline yard for approximately 5 minutes; and
b. it was substantiated that the student was not directly supervised by a staff
member while in that area.
30. Justitia found that this incident occurred in breach of Bendigo SDS practice, which
requires that the door to the clothesline yard must remain open at all times when a student
is in that area. The relevant ESS who accompanied the student to the clothesline yard was
not aware that the door to the clothesline yard must remain open if a student is in the
yard. This ESS had completed a two week placement at Bendigo SDS and was working a
fifth subsequent casual relief shift on the day that this incident occurred.

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31. Justitia did not conclude that the clothesline yard was an inappropriate place for the
student to be. Rather, given that the relevant student chose to go outside and likes being
outside (and importantly, being outside is one of the methods by which the student can
self-regulate), it was found that the clothesline yard was an appropriate place for that
student to go, provided that the external door leading to the courtyard is open so that the
student can move freely between the kitchen area and the courtyard.
32. In relation to the Clothesline Yard Allegations, Justitia recommended that:
a. a sign be placed on the door which leads from the laundry to the clothesline
yard which states that the door must remain open if a student is outside;
b. a sign be placed on the door which leads from the kitchen to the laundry which
states that the door must remain open if a student is outside; and
c. the supervising teacher in the caf program conduct an induction for casual
relief teachers and/or assistants who have not previously worked in the caf
program, which specifically includes an instruction that both the external door
(to the clothesline yard) and the door from the kitchen to the laundry are to
remain open at all times if a student is outside in the clothesline yard.
33. In respect of the Training Allegations it was substantiated that there were training
sessions at Bendigo SDS conducted by self-defence instructors. It was not substantiated
that the focus of the training was on techniques to move or restrain students. The
evidence supported a finding that the focus of the training sessions was on how to employ
evasive techniques when a student becomes aggressive. During a training session, the use
of pressure points techniques was referred to as a last resort for use in times of
emergency (e.g. if a student has dropped on a road).
34. In respect of the Pressure Points Allegations, it was not substantiated that the ESSs had
used pressure points on the student as alleged in Room 5 in 2009. However, there was
evidence to indicate that an ESS was about to use pressure points on the student but,
following instruction from a teacher, had not actually done so.
35. Justitia found that it was not substantiated that the relevant ESS had used pressure points
to make a student stand up in October 2014. However, Justitia found that the ESS had
used the word pressure in an explanation of the technique used to guide the student to a
standing position using open hands under the arms.
36. In respect of the Water Bottle Allegation, the relevant teacher did not recall this incident
and denied that it occurred. However, the teacher stated that she used a misting spray
bottle as a strategy for cooling herself down, and sometimes students would ask her to
spray mist on them, but that she would never do this if they did not want her to. The
teachers evidence was that the classroom doors are unlocked from the outside but locked
from the inside because some students were a flight risk. It was not substantiated that
the teacher would not let the relevant parent and student leave the classroom until the
student stopped crying.

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37. In relation to the Pen Allegation, it was substantiated that the student was assisted to a
safe enclosed space when the students behaviour escalated, in accordance with the
students Behaviour Management Plan.
38. In respect of the Lunch Allegation, it was substantiated that in 2014, the respondent
teacher taught a student who would self-abuse and drop to the floor. It was substantiated
that the teacher sometimes asked the student to walk out of the class with an ESS member
when the students behaviours escalated, for the students own safety and for the safety of
others. It was found that the students lunch may have been delayed for the students own
safety when the students behaviours escalated. It was not substantiated that the teacher
withheld the students lunch or made the student walk out of the class for any punitive
reason.
39. In relation to the Shopping Centre Allegation, it was substantiated that the teacher left a
student at The Market Place, Bendigo, during a community access visit on 24 October
2014. The teacher provided a fulsome explanation as to the circumstances which led to
the student being left at The Market Place. The student absconded from the student group
and returned brandishing a two foot long stick. The teacher called Ms Hommelhoff and
also called the police. The student absconded again. The teacher returned the other
students in her care to Bendigo SDS. The police attended The Market Place, retrieved the
student and returned him to Bendigo SDS. It was not substantiated that Ms Hommelhoff
said the student was street smart and will find his way home.
40. In relation to the Funding Allegations, it was substantiated that Bendigo SDS retained a
students Level 4 PSD funding in 2010. However, it was found that Bendigo SDS and the
DET had not been formally notified by the parent that the relevant student would not be
returning to school and had not been provided with a transfer notice.
41. In respect of Student Assault Allegation 1, Justitia found that the evidence did not
substantiate the allegation that the teacher had driven the students head into the ground,
causing it to split open. The evidence indicated that the student had fallen and received a
minor cut near the eyebrow while attempting to kick the teacher. There was no evidence
of any breach of the teachers duty of care to the student during this incident.
42. In respect of Student Assault Allegation 2, Justitia found that there was insufficient
evidence to substantiate the allegation. The allegation was denied and there was no
corroborative witness evidence to support the allegation.
43. In respect of the Bruising Allegations, Justitia found that the evidence did not
substantiate that the parent had met with Ms Hommelhoff and the teachers on two of the
occasions over 2011-2012 as alleged. There was evidence to support a finding that the
parent had met with Ms Hommelhoff in June 2012, but the evidence did not substantiate a
finding that Ms Hommelhoff was dismissive of the parents concerns.

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44. Justitia found that there was insufficient evidence to substantiate the finding in respect of
the teacher being dismissive of the relevant parents concerns about bruising in March
2009.
45. In respect of the Communication Allegations, it was substantiated that:
a.

two versions of an Intellectual Assessment Report were prepared for a student

by an independent assessor and the version of the report provided to the
students parents contained different information to that in the report provided
to Bendigo SDS;

b.

the same parent referred to above received a placement letter for a student for
2011. However, it was not substantiated that the parent had formally advised
the school and the DET that the student would not be returning to school;

c.

when a student ceased enrolment at Bendigo SDS in 2015, Ms Hommelhoff

told the parent they would need to make an FOI request in respect of any
incident reports. It was not substantiated that Ms Hommelhoff told the parent
to make an FOI request in respect of the students file; and

d.

Ms Hommelhoff did not inform the relevant parent about an alleged incident
reported to her with respect to an ESS staff member applying a pressure point
technique to a student.

46. Justitia also found that the information included in communication diaries between
parents and teachers may not always be fulsome or useful, and that, while parent access to
the school grounds is not restricted, there is a level of confusion for some parents
(particularly with those who have non-verbal children) about the schools motivations for
asking parents not to accompany their children into the school grounds beyond the bus
bay. Justitia recommended improved communication from the school to assist in allaying
the concerns communicated by some parents.

_______________
Justitia
18 March 2016

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