Australia stands at the precipice of an aged care crisis that threatens to overwhelm the sector’s capacity to provide safe, quality care.
The numbers paint a sobering picture: Australia’s workforce shortage in aged care is likely to reach 110,000 by 2030, while the number of Australians over 80 and the complexity of their clinical needs, is projected to grow exponentially.
Against this backdrop, the government’s response to the aged care sector’s problems—while well-intentioned—may be inadvertently exacerbating the very issues it seeks
to resolve.
The 2019 Royal Commission into Aged Care Quality and Safety exposed widespread failures across the sector, leading to the establishment of the Aged Care Quality and Safety Commission and significant legislative reforms.
Central to these reforms was the Serious Incident Response Scheme (SIRS), which commenced in April 2021, aiming to reduce the risk and occurrence of abuse and neglect being perpetrated towards older Australians.
Yet nearly four years later, the scheme appears to be creating more problems than it solves.
Defining quality and safety in aged care is far more complex than it initially appears. Quality care means different things to different consumers: for some, quality is about choice, social connections, and lifestyle preferences; for others, it’s the technical precision of clinical procedures, timely medication administration, and clinical coordination of care.
The same is true for service function and desired outcome; consider comfort, style and flavour, or timeliness, accuracy and error free. This variability makes standardised quality measures challenging to implement and assess, but it also highlights the nuanced nature of care that regulatory frameworks struggle to capture.
Safety, meanwhile, must be understood within the context of clinical risk. All healthcare environments – including aged care – are inherently high risk, with adverse events arising from various causes, stemming from the complex interplay of human factors, system limitations, and the factors of the populations being served, such as frailty.
The critical distinction lies between clinical adverse events that occur despite best practice and genuine cases of clinical negligence, recklessness or abuse. This distinction cannot be overstated as it has profound implications for how we respond to incidents and, ultimately, how we improve care.
The Serious Incident Response Scheme has 8 reporting categories; unreasonable use of force, unlawful sexual contact or inappropriate sexual conduct, psychological or emotional abuse, unexpected death, stealing or financial coercion by a staff member, neglect, inappropriate use of restrictive practices and unexplained absence.
The Commission reports receiving approximately 60,000 SIRS notifications annually, with Neglect being the second-most common incident type (following Unreasonable Use of Force). In Q1 2024-25 alone, there were 3,950 notifications of neglect reported—an 11% increase from the previous quarter and 26% year-on-year.
The legislation supporting the scheme defines Neglect as “a breach in duty of care or gross professional misconduct,” with the Commission publicising reported cases of Neglect including medication errors in 46% of cases, falls in 21%, unmet personal care needs in 17%, and pressure injuries in 8%.
Here lies the fundamental problem: the current scheme clearly conflates clinical adverse events (medication error, falls, pressure injuries) with intentional wrongdoing (psychological abuse, theft, sexual assault).
Research consistently shows that individual blame contributes to a very small percentage of clinical errors (often less than 1%), yet the SIRS framework appears to treat routine clinical incidents as evidence of professional misconduct or wrongdoing – at an alarming rate.
This approach contradicts and compromises decades of patient safety research that emphasises system-based solutions over individual blame, and it places thousands of dedicated aged care workers under suspicion for outcomes that are often beyond their individual control.
The implications extend far beyond bureaucratic processes. Aged care providers and advocates routinely report it is difficult to attract and retain staff, and they can’t meet the growing demand for services from older people.
The current approach to SIRS incident reporting creates a climate of fear among healthcare workers, who face the prospect of being reported for professional misconduct when adverse events occur in their practice.
This fear permeates the sector, affecting not just those directly involved in reported incidents but creating a culture where staff become reluctant to engage with challenging cases or report near-misses that could inform system improvements.
This fear-based culture has predictable consequences that undermine the very safety goals the system seeks to achieve. Reduced reporting means fewer opportunities to identify system vulnerabilities and implement preventive measures.
Increased staff turnover in an already stretched workforce leaves remaining staff more overworked and prone to the very errors the system seeks to prevent. Healthcare workers become “second victims” of adverse events, experiencing psychological harm that affects their wellbeing and their capacity to provide quality care.
The tragic case of an elderly Gold Coast couple who took their own lives rather than enter residential care illustrates the broader societal impact of the sector’s damaged reputation and the crisis of confidence that extends far beyond the walls of aged care facilities.
Healthcare systems worldwide have actively moved away from punitive, blame-focused approaches to patient safety, learning from decades of research into human factors and system design.
Contemporary safety systems further consciously ensure that even the perception of a blame-focused system is avoided due to the integrity of the system’s reliance on trust.
The concept of “just culture”—which distinguishes between system failures, human factors, and genuinely reckless behaviour—has become the gold standard in patient safety.
High-reliability industries like aviation have demonstrated that safety improves when reporting is encouraged, not penalised, and when investigations focus on system vulnerabilities rather than individual fault-finding.
These approaches have transformed acute healthcare settings, reducing errors while supporting healthcare workers and improving outcomes for patients.
Yet aged care remains trapped in an outdated paradigm that seeks individual culprits for systemic problems.
When a medication error occurs, the focus (or even the perceived focus) lands on the individual nurse rather than examining the system factors that contributed to the error: inadequate staffing ratios, poor medication storage systems, interruptions during medication rounds, or unclear prescribing practices.
When a resident falls, attention turns to whether the staff member followed protocols rather than assessing whether the environment, staffing levels, or care planning systems created conditions where falls were more likely to occur.
Recognition of these issues appears to be emerging, albeit slowly. The upcoming changes to the Aged Care Act, scheduled for November 2025, will redefine Neglect as “intentional harm or recklessness”—a significant improvement that provides clearer boundaries and aligns more closely with evidence-based approaches to patient safety.
This change acknowledges the difference between deliberate harm and the adverse outcomes that occur despite good intentions and reasonable care.
However, if the Commission continues to receive similar volumes of reports under this new definition, it suggests a sector in genuine crisis, with widespread intentional harm occurring across thousands of facilities.
The more likely scenario is that most incidents represent the inevitable adverse outcomes of caring for increasingly frail populations within resource-constrained systems operated by dedicated staff doing their best under challenging circumstances.
The question then becomes whether the regulatory framework can evolve fast enough to support these staff rather than criminalise them.
The path forward requires acknowledging that meaningful improvement in aged care safety will come not from finding individual scapegoats but from building resilient systems that support both care recipients and the dedicated professionals who serve them.
This means implementing evidence-based patient safety principles borrowed from acute care settings, where sophisticated incident analysis, system redesign, and culture change have dramatically improved outcomes.
It means distinguishing clearly between system failures and individual misconduct, encouraging incident reporting to drive system improvements rather than punishment, and supporting healthcare workers as partners in safety improvement rather than subjects of an investigation.
Most critically, it requires meaningful investment in system redesign, workforce development, and quality improvement infrastructure.
To truly provide equitable care to older Australians the aged care sector needs the same sophisticated safety culture that has transformed other high-risk healthcare environments, complete with robust incident analysis, systematic approach to risk reduction, and a culture that learns from errors rather than hiding them.
Australia cannot afford to wait decades for the Commission to recognise that its current approach may be perpetuating rather than mitigating harm.
The workforce crisis is deepening, public confidence is waning, and the generation of Australians who built this country deserves better than a system that treats their care providers as potential criminals rather than essential workers operating in challenging circumstances.
The challenges facing Australian aged care are real and urgent. An ageing population, workforce shortages, and increasing care complexity require sophisticated, evidence-based responses.
The current approach to incident reporting, while well-intentioned, risks undermining the very outcomes it seeks to achieve by driving away the very people we need most:
compassionate, skilled healthcare workers committed to providing quality care for older Australians.
The question is not whether Australia can afford to make these changes, but whether it can afford not to. True improvement in aged care safety requires courage to move beyond blame and embrace the complexity of caring for our most vulnerable citizens.
It requires recognition that the vast majority of aged care workers come to work each day with the intention of providing the best care possible, and that our regulatory systems should support rather than undermine this fundamental commitment to care.
Only then can we build an aged care system worthy of those it serves and those who dedicate their careers to serving others.
