Australian Foundation for Disability (Afford), a registered charity, was ordered to pay $400,000 for two contraventions of the NDIS act in the Federal Court on Wednesday, as well as costs for the NDIS quality and safeguards commissioner bringing them to court.
Justice Wendy Abraham noted there were "obvious inadequacies" in the care given to Merna Aprem before she drowned at Afford's group home at Woodbine in Sydney's southwest on May 23, 2019.
Ms Aprem could not be revived after she was found unconscious with her nose and mouth submerged in a bathtub of water and vomit.
Two workers were on duty to look after her and two other residents on the night she died, neither of whom had worked at the home before or knew she had epilepsy.
Ms Aprem was left in the bath unsupervised with the door ajar for 25 minutes, and was able to lock herself in.
Staff had to dismantle the door knob with a kitchen knife to access the bathroom after she did not respond.
Triple zero was not called for more than 20 minutes.
Afford failed to develop and implement a full plan to manage her epilepsy and did not ensure a review of her seizure controls as part of a health assessment.
Days before she moved to Woodbine in March 2019, an Afford team leader noted in an email Ms Aprem "needs all medical forms completed by GP", after being referred to Afford in November 2018.
Afford also did not ensure workers caring for Ms Aprem understood she had epilepsy and could have a seizure while bathing, and did not ensure she was adequately supervised.
It accepted it failed to provide support in a safe and competent manner and failed to ensure Ms Aprem could safely access appropriate support for her needs.
Those failures placed Ms Aprem at a real and significant risk, and may have caused or contributed to her death.
Afford admitted its conduct was "negligent and careless", but was not deliberate or reckless.
"I agree with the (NDIS commissioner) that one can hardly imagine more serious consequences," Justice Abraham wrote in her published judgment.
A NSW coroner has previously deferred a decision on whether to hold an inquest in Ms Aprem's death until the Federal Court proceedings were finalised.
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