Independent review into circumstances relating to the death of Ann-Marie Smith

Review conducted by the Hon. Alan Robertson SC into issues surrounding the death of Ms Ann-Marie Smith.

Our media release of 26 May 2020 announced the appointment of the Hon. Alan Robertson SC to conduct an independent review into the NDIS Commission’s regulation of the provider of NDIS supports and services to Ms Ann-Marie Smith, an NDIS participant.

The terms of reference of this review are attached.

Organisations and members of the public were invited to provide information or make a submission to Mr Robertson.

Mr Robertson was required to conduct the review in a manner that avoids prejudice to any pending or current criminal or civil proceedings.

Mr Robertson's report to the NDIS Quality and Safeguards Commissioner is attached. You can read the media release and view the video of Mr Robertson reading the summary of his report.

Ms Smith died on 6 April 2020 in appalling circumstances. Her death is the subject of active investigation by the NDIS Commission and by South Australia Police.

Meetings in Adelaide 20 and 21 July 2020

On 20 and 21 July 2020, Mr Robertson held meetings in Adelaide with those who provided a submission or an outline of what they wished to say to the independent review.

The meetings were broadcast via live stream and, as much as possible, were accessible to the public. However, the broadcast was turned off, where necessary, in circumstances where the discussion was about individuals or contained individual information and where this information may prejudice or interfere with ongoing enquiries or any potential civil or criminal proceedings as per the Review’s terms of reference.

Transcripts of the publicly accessible sessions of these meetings are attached. Please note: these are uncorrected versions of the transcripts, which may contain typos.

Video recordings of the public webcasts are available:

Joint Statement on the Approach to Supporting at Risks participants

In June 2022, the NDIS Quality and Safeguard Commission and the National Disability Insurance Agency released a Joint Statement in relation to what has been done both singularly and jointly to progress the findings of the Robertson Review in response to the death of Ms Anne-Marie Smith. The Joint Statement provides an overview of the many actions taken to date representing substantial improvements in safeguarding for NDIS participants.

Other Reports

Final report of the consultation with stakeholders for the NDIS Commission regarding Regulatory Recommendation 2 in the Robertson Review into circumstances relating to the death of Ann-Marie Smith

In May 2020 the NDIS Commission began major compliance activities to assess and monitor risks to NDIS participants.  In the same month the review conducted by the Hon. Alan Robertson SC into circumstances relating to the death of Ms Ann-Marie Smith began.

In October 2020, the NDIS Commission applied a condition of registration on providers registered to deliver the class of support ‘Assistance with daily personal activities’. This interim measure was introduced in response to  the compliance activities and Regulatory Recommendation 2 of Robertson Review.

In March 2021, the NDIS Commission engaged Discourse Consulting to consult with a wide range of stakeholders to gauge views on a possible change to the NDIS Rules to make the requirements imposed through this condition of registration more permanent. That consultation is now complete.

The final report resulting from this consultation, along with a cover note from the NDIS Commission, is available here.

Related resources

Final stakeholder consultation report for Regulatory Recommendation 2 in the Robertson Review into circumstances relating to the death of Ann-Marie Smith

Independent review - Terms of reference

The Hon. Alan Robertson SC - Curriculum Vitae

Day 1 transcript (20 July 2020)

Day 2 transcript (21 July 2020)

Independent review - Report to the Commissioner

Joint Statement on the Approach to Supporting at Risk NDIS participants