From silence to accountability: What happens when institutions truly listen
Jingeri – hello in Yugambeh language.
I want to acknowledge the Kombumerri people and the Yugambeh nation, traditional custodians of the land on which we meet. I want to pay my respects to Elders past and present.
I extend that respect to Aboriginal and Torres Strait Islander peoples here today.
I also want to acknowledge the enduring wisdom of Aboriginal and Torres Strait Islander cultures, and in particular the role of Elders. One of the things I have always admired is the way many First Nations communities understand ageing.
Eldership is not viewed as something to be endured. It is recognised as something that brings value. Elders are holders of culture, memory and knowledge. Their voices matter because the community understands that it is stronger when those voices are heard.
I have found myself thinking about that a great deal in my work in aged care and elder abuse. Because, while elder abuse is a safeguarding issue, it is also – at some level – a question about value.
A society that values older people, that seeks out their wisdom, that notices their contribution and listens seriously to their experience, creates fewer opportunities for older people to disappear from view.
Whereas a society that talks about ageing mainly as decline, cost, or dependency risks making older people less visible. And when people become less visible, their rights become more fragile, and vulnerability to abuse increases.
That thought sits underneath much of what I want to talk about today.
Because what I want to talk about is not ‘abuse’ per se, but about visibility. And about institutions: whether they remain connected to the reality of people’s lives, what happens when they do not, and what kind of public policy architecture we need if we are serious about finding harm before it escalates.
I want to explore 3 related ideas.
The first – you might have already guessed – is that elder abuse is not simply a safeguarding issue. It is also a visibility issue, shaped by the way we value older people in our communities.
The second is that disclosure is an inadequate foundation for safeguarding, even though many of our systems still rely on people being able to recognise harm, name it, report it and persist until someone responds.
And the third is that if we are serious about prevention, we need systems that do not simply wait for harm to be reported. We need systems that create visibility by design, through advocacy, oversight, independent scrutiny and policy settings that reward earlier identification of risk.
How we respond when people stand up and speak out remains essential. But I want to focus today on how institutions, governments and communities develop the curiosity and courage to ask what is not being said.
So, thank you for inviting me to stand up and speak out!
The conference title really resonates with me because when we say “Stand Up, Speak Out”, it immediately directs our attention to courage. The courage required to raise concerns, the courage required to challenge power, and the courage required to speak a truth that others may not want to hear.
I want to acknowledge that many of the most important reforms in Australia have begun because somebody was prepared to stand up and speak out when silence would have been easier. Many of the most important reforms in Australia have begun not with certainty, but with discomfort. A family member who felt something wasn't right. An advocate who kept hearing the same story. A survivor who challenged an account that others seemed prepared to accept. What mattered was not that they had all the answers. What mattered was that they refused to let the questions disappear.
That courage matters. It always will.
But today I want us to contemplate a different question: What happens when people do not speak out? Or, perhaps more accurately, what happens when they cannot?
Because the longer I spend in oversight and safeguarding roles, the more I find myself troubled by how much responsibility we place on people experiencing harm to be the ones who reveal it.
We tell people to speak up. We tell them to complain. We tell them to disclose. We tell them to report concerns and navigate processes and repeat their experiences to people they may not know or trust.
Of course, there must always be safe pathways for people to do those things.
But I remain of the view right across our public policy settings, that we ask too much of individuals and too little of institutions. And I see this particularly to be the case in aged care.
We should not build safeguarding systems that depend primarily on people's courage, their ability to identify what is happening to them as wrong, or their capacity to navigate complex complaints and advocacy pathways. Yet, time and again, inquiries and Royal Commissions across different sectors have exposed precisely that assumption.
If you think about it, how many times have we heard this lesson repeated? Across inquiry after inquiry, and Royal Commission after Royal Commission, we are reminded that many people experiencing harm never disclose it at all. Others do so only after significant damage has already been done.
Because disclosure is not prevention; rather disclosure is what happens after something has already gone wrong. And if we build safeguarding systems that rely too heavily on people telling us about harm after the event, then we have already accepted a great deal of risk.
I will talk about this today through the lens of aged care but, as I said, the questions I raise here are not confined to aged care. They arise in every setting where people depend on institutions for care, support, protection or safety.
And it turns on one question in particular: How do institutions know what is really happening in the lives of the people they serve?
Most organisations can answer that question quite quickly. They can point to their complaints data, incident reports, audits, surveys, quality indicators, accreditation outcomes and board reports.
And all of those things matter.
But I have become increasingly cautious about the confidence institutions draw from the information they already hold. Because there is always another category of information: the information that never enters the system.
It’s the complaint that is never made, or the concern that someone isn’t certain about but something just feels a bit dodgy, or the family member who decides the matter is not worth pursuing. And pervasively, it’s the older person who quietly concludes that nothing will change.
All of that is data too.
The challenge is that institutions are often extraordinarily good at understanding the information that reaches them, but are much less equipped to understand the experiences that never enter the system in the first place.
And those experiences may tell us just as much about safety as the data institutions rely on most. Perhaps more.
Silence is a very poor measure of safety. I hear this from older people every day – and I think this has been the driving message of almost every Royal Commission in this country – not just in aged care.
Over time I have become wary of systems that draw too much comfort from the absence of concerns. Human beings do not automatically complain when something is wrong. They hope problems will resolve themselves. And sometimes they simply decide that pursuing the issue will take more from them than they have left to give.
That reality should make all of us cautious about treating silence as evidence that people feel safe.
When governments design systems, we can sometimes talk about complaints and pathways as though people move through them logically and confidently. The reality is often much more complicated.
People weigh consequences. They think about relationships. They worry about whether they will be believed. They worry about whether services might become more difficult, whether staff might treat them differently, whether a family relationship might deteriorate, whether the effort of complaining will be greater than the likely result.
And some people have already learned – through experience – that speaking up does not always change very much.
For some older people, the hesitation to raise concerns runs even deeper. Many Forgotten Australians, members of the Stolen Generations, care leavers and others who have been forced into institutional settings have lived through experiences where speaking up was ignored, punished or simply made no difference.
Some learned very early in life that authority figures could not be trusted, that complaining could make things worse, or that survival depended on keeping your head down rather than drawing attention to yourself. Those lessons can endure for decades.
It means that when we ask why some older people do not disclose harm, we need to be careful not to interpret silence as comfort or consent. For some people, silence may reflect a lifetime of experience that has taught them it is safer not to speak.
That is why I have argued elsewhere that rights cannot depend solely on self-advocacy. It is also the very reason why trauma-informed and trauma-responsive approaches are not an optional extra in safeguarding. They are fundamental to understanding how people interact with institutions and whether they feel safe enough to trust them.
What this ultimately comes down to is this: a right that depends on a person recognising it, asserting it and fighting for it is at risk of becoming not much more than a symbolic right.
When I step back and look at safeguarding systems across social systems more broadly, I keep returning to the same uncomfortable questions: why do we place so much of the burden of detecting harm on the people most likely to be affected by it? Why do we assume they will recognise what is happening, understand their rights, navigate complex systems and then persist until somebody listens?
I suspect part of the answer lies in how we think about ageing more broadly.
As you know, elder abuse does not emerge in isolation from community attitudes or institutional culture. Like all forms of abuse, it occurs within a social environment that influences whose voices are heard, whose concerns are taken seriously and whose experiences are regarded as important.
The way we talk about ageing contributes to the problem we are trying to solve. Much of the public discussion focuses on demand, costs, and the growing need for care and support. Those things are real, but they can inadvertently narrow how we see older people.
And it’s not simply a question of language. The way we talk about ageing influences what we notice and what we overlook. If older people are discussed mainly in terms of the services they require, it becomes easier to lose sight of them as citizens with knowledge, preferences, relationships, and continuing contributions.
And, once that happens, it becomes much harder to recognise when their voices are not being heard or when their rights are being diminished.
As you know, abuse rarely appears out of nowhere. More often, it is the end point of a gradual erosion of voice, choice and agency.
Long before anyone uses words like abuse or neglect, people can find themselves being less consulted about decisions that affect them, less able to influence what happens in their own lives, and more expected to adapt to the needs of a system than have the system adapt to them.
That is why ageism matters so much. Not simply because it is offensive or unfair, although it is both. It matters because it changes what we notice. It changes what we tolerate. It changes how quickly we respond when something does not seem right.
If societal attitudes help create the conditions in which abuse can occur, institutions play a different role. They shape whether those risks are recognised, taken seriously and acted upon.
And that brings me specifically to aged care.
One of the realities we rarely acknowledge in aged care is that, despite decades of policy moving away from institutional models in other sectors, aged care remains one of the few parts of the human services system where institutionalisation remains a central feature.
In child protection, disability and mental health, there has been a deliberate shift towards community-based models, driven in part by a recognition that institutional settings can create particular risks and power imbalances.
Apart from prisons, aged care is now one of the few sectors where large numbers of people continue to live, receive care, and spend much of their daily lives within institutional environments.
That is not to disparage the people working within them. Most people working within residential aged care facilities are deeply committed to providing safe and compassionate care.
But it does mean we should pay close attention to what decades of inquiries and Royal Commissions have taught us about institutional life. Institutions develop cultures, assumptions and routines. They shape how people understand the world around them. Over time, they can become very good at seeing some things and surprisingly poor at seeing others.
One of the lessons from Royal Commissions and major inquiries is that institutions can fail in ways they themselves struggle to recognise.
When we look back at institutional failures, we often ask how nobody knew.
More often, people did know something. Families knew fragments. Staff knew fragments. Advocates knew fragments. Managers knew fragments. Regulators sometimes knew fragments. The problem was not always a total absence of information.
The problem was that the information sat in different places, was interpreted through different lenses, and never forced the institution to confront its significance.
So that clearly demonstrates to me that safeguarding is not simply about collecting more information. I think that tells us that safeguarding in institutional settings is about creating cultures that can notice weak signals and take them seriously. It’s about asking another question when the first answer is too reassuring. And it’s about resisting the very human tendency to prefer information that confirms what we already hope is true.
Every organisation wants reassurance. Boards want to know that risks are being managed. Staff want to feel proud of the care they provide. Regulators want evidence that standards are being met.
None of that is wrong. But reassurance can become seductive.
Sometimes institutions become more interested in proving that things are functioning than in discovering where they are not.
And that is where I think independent institutional oversight has such an important role. During my time as Public Guardian in Queensland, I was responsible for a legislated Community Visitor scheme operating across disability, mental health, child protection and youth detention settings.
These were not volunteer visitors providing companionship. They were independent statutory office holders, empowered to enter services on a regular basis, meet privately with people, advocate on their behalf and report concerns about both individual circumstances and systemic issues. They enter environments that could otherwise become closed to outside view, observe the reactions of older people and form relationships and trust so that truth can be shared without fear.
The underlying premise is simple: we cannot assume that people experiencing harm will always be able to raise concerns, or that concerns will automatically find their way to those with the power to act.
Aged care is one of the largest systems of care and support in this country. It reaches into people’s homes, into those institutional settings and supports people at moments of significant vulnerability, including in the earliest moments of death.
So, by definition, it involves profound dependency and trust.
That does not make aged care uniquely dangerous; but it does mean aged care requires particular vigilance.
I am not saying that community visitors alone, or advocates alone are the answer to every problem. No single mechanism is.
Community Visitors and advocates perform different roles. One is a legislated form of independent oversight, established because we recognise that some concerns will never come to light unless somebody is empowered to go looking for them. The other provides representation, support and voice for people whose experiences might otherwise remain unheard.
But what they have in common is that both create visibility. Both help systems see things they might otherwise miss. And both recognise that safeguarding becomes stronger when institutions do not rely solely on complaints or disclosure to understand what is happening.
Our advocates – whether formal or informal – equally perform a most critical function. In aged care, we are lucky to have them, because it’s exactly that vigilance that makes our existing advocacy services and all the unsung voluntary advocates and advocacy so indispensable.
Advocates sit close to people’s lived experience. They hear the stories that do not arrive neatly framed as compliance issues. They hear what life feels like for people trying to navigate care, relationships, dependency and fear. Over time, those individual stories begin to reveal patterns.
That is one of advocacy’s great strengths. An individual concern may be easy to dismiss as isolated. A repeated concern, heard in different places from different people, starts to tell us something else.
The truth in aged care reform is that many of the issues now regarded as obvious were not obvious when advocates first raised them. They became obvious because advocates kept raising them. Because advocates refused to let lived experience disappear into administrative language.
That is why I regard advocacy as part of the moral infrastructure of aged care. Independent advocacy and independent oversight are not the same thing, but both create visibility. One helps ensure people have a voice. The other helps ensure systems are paying attention. Together, they do more than hold services accountable. They help illuminate what is happening in people's lives and, in doing so, provide a clearer guide to where policy, practice and reform should go next.
I saw that repeatedly during my time as Public Guardian in Queensland. Community Visitors, with legislated rights of entry and oversight responsibilities, often developed a different perspective from advocates working alongside people and families. Yet it was often when those perspectives were brought together that the most complete understanding emerged of what services were doing well, where risks were emerging, and where change was needed.
Rules, standards and regulations all have their place, but they are not a sufficient safeguard.
Systems also need people whose primary loyalty is to the person whose voice might otherwise be invisible. I think that is one of the most powerful safeguards we have.
Abuse, neglect and rights erosion are harder to sustain when people know someone is paying attention.
The lesson is that safeguarding becomes stronger when systems are designed to look, not merely to receive. There is a profound difference between waiting for information to arrive and actively seeking out what may otherwise remain hidden.
And that brings me to the third part of what I want to say today.
If elderly people can become less visible because of ageism, and if institutions can become over-reliant on disclosure and complaints, then reform has to be about creating visibility by design.
By that I mean: deliberately building structures that make it more likely that harm, neglect, coercion or exploitation will be identified before serious damage has occurred.
Financial abuse provides an important example.
If an older person’s finances are being manipulated, the first indication may not appear in an aged care service, a regulator’s office or even a family conversation.
It may appear in a bank. When I was Public Guardian, with unique powers to intervene in elder abuse, it was banks that were most often the key identifiers that something was wrong: A transaction pattern changes. A person who has always managed their own affairs appears to lose control of them. Someone else begins exerting influence. Something about the movement of money stops making sense.
That does not mean a bank can or should become the entire safeguarding system. But it does mean we need a broader national conversation about who sees what.
Because abuse rarely reveals itself completely to one organisation. It often reveals itself in fragments. Health professionals may notice things others do not. Pharmacists may notice changes in medication use or distress. Families may see shifts in behaviour. Banks may see financial exploitation before anyone else.
Viewed in isolation, those things can sometimes seem unremarkable but viewed together, they can tell a very different story.
So, the question becomes: how do we build a safeguarding ecosystem that recognises the importance of those fragments? How do we make sure organisations that see early warning signs understand that they have a role in preventing harm, even if they are not traditionally thought of as part of the aged care system?
We need a mature national conversation about how to respect autonomy while also recognising that some harms are visible only if multiple parts of the community understand their role in noticing them.
We tend to look for solutions within individual organisations or sectors, but harm does not organise itself that neatly.
If the warning signs are dispersed across different parts of a person's life, then preventing abuse requires a collective willingness to notice, to ask questions and to remain curious about what may be happening beneath the surface.
In that sense, safeguarding is not simply a regulatory responsibility. It is a social one.
But when I say safeguarding is a social responsibility, I do not mean governments can step back. Quite the opposite.
If we genuinely accept that disclosure alone is not a sufficient safeguard, then governments have a responsibility to design systems that do not depend on disclosure alone.
We should be asking a larger question: What structures does a society put in place when it accepts that many people experiencing harm will never complain, that some concerns only become visible through independent eyes, and that institutions are not always best placed to identify their own blind spots?
Because stronger safeguarding cannot rest solely on the goodwill, competence or vigilance of individual organisations. It requires architecture.
One of the things I learned as Public Guardian in Queensland was the value of creating visibility by design rather than hoping it emerges by accident.
The Community Visitor Program existed because Parliament recognised a simple reality: some people live in environments where concerns may never surface unless somebody independent is empowered to go looking for them.
The answer was not to wait for complaints. The answer was to create visibility.
For many years we have funded advocacy in aged care. But the next question is whether advocacy should be regarded not simply as a program, but as a core safeguard of the aged care system itself.
If we accept that advocates hear things others do not, identify emerging issues before they become systemic problems and provide trusted pathways for people who may never approach a regulator or provider directly, then there is a strong argument that independent advocacy should be treated as essential infrastructure rather than discretionary support.
The same is true of visibility more broadly.
The challenge for government when it comes to aged care holistically, is: how we move beyond a model of safeguarding that is primarily complaint-driven? That makes it imperative we invest in independent mechanisms that create visibility before harm escalates. That we strengthen advocacy not as an optional support, but as a safeguard. And that we create more pathways for older people to be heard without requiring them to become complainants.
Beyond aged care, as a society we need to think much more deliberately about how different parts of our community see different fragments of risk, and how those fragments might be brought together before serious harm occurs.
Decades of Royal Commissions show that we are often very good at investigating abuse after it has been discovered. The harder task is creating systems that are capable of finding it earlier.
And that, I think, is where the next chapter of reform lies. Not simply in responding better; but in seeing better.
When institutions truly listen, they do more than hear what is said. They ask why some things are not being said. They become interested in the experiences that have not reached them. They treat absence of information as a reason for curiosity, not reassurance.
So, as I reflect again on the theme of this conference, I think that "Stand Up, Speak Out" means going beyond just encouraging people to voice what they see and hear. “Stand Up, Speak Out’ also conveys the responsibility to remain curious about what is not being said.
To notice when someone becomes quieter. To question reassuring assumptions. To be interested in the gaps between what a system knows and what a person may actually be experiencing.
In that sense, speaking out is only part of the challenge. The other part is having the curiosity to question silence and the courage to pursue answers that may be uncomfortable.
As I come towards the end of my time as Inspector-General, I find myself returning to that question more than any other. What are we not seeing?
The task for governments is to create policy settings that reward visibility, strengthen independent safeguards and support earlier identification of risk. The task for organisations is to create cultures that remain open to uncomfortable information and willing to question reassuring assumptions.
Because the goal cannot simply be to respond when harm becomes visible. It must be to create systems that care enough to go looking for what they cannot yet see.
Thank you.