Not-for-profit provider ordered to pay $30,600 after medication error results in National Law breaches

The State Administrative Tribunal has ordered Goodstart Early Learning Ltd, trading as Goodstart Early Learning Atwell, to pay $30,600 in disciplinary penalties after a three-year-old child received four times the prescribed dose of medication, resulting in multiple breaches of the Education and Care Services National Law (WA) and the Education and Care Services National Regulations (WA).

The decision in CEO of Department of Communities v Goodstart Early Learning Ltd t/as Goodstart Early Learning Atwell [2026] CC 467 follows an agreed settlement between the Department of Communities and the provider. The Tribunal accepted an agreed statement of facts and found there was proper cause for disciplinary action under section 188AB of the National Law.

The incident occurred on 9 October 2025 when a child aged just more than three years, who had a serious medical condition requiring carefully managed medication, attended the service.

According to the agreed facts, the service had 49 children in attendance that day, including 27 children in the Kindy group. Three educators were working with the group. While the service had established medical management procedures, neither educator directly involved in administering the child's medication had received external training in managing the child's specific medical condition.

Before lunch, the child was provided with a snack in accordance with the child's medical management plan before returning indoors for lunch preparations. To determine the correct medication dosage, an educator was required to enter food intake data into a phone application. During the process, the educator assisted another child, served food and then moved to settle children for rest time.

The Tribunal accepted that the documented process for calculating the medication dosage was not followed, resulting in the child receiving four times the prescribed dose. The error was identified shortly afterwards and the child received immediate treatment before being collected by a parent, who sought further medical advice from Perth Children's Hospital.

The Tribunal found Goodstart contravened section 167(1) of the National Law by failing to ensure every reasonable precaution was taken to protect children from harm and hazards likely to cause injury.

The agreed facts identified a number of contributing factors, including incomplete staff acknowledgement records demonstrating that not all educators responsible for the child's care had read and understood the child's medical management plan. The investigation also identified outdated information within the child's medical management documentation, including inconsistent references to where medication was stored, and found the service had not undertaken auditing to verify staff understanding or competency.

The Tribunal further noted that the child's parents had raised concerns during 2025 regarding educator knowledge and confidence in administering medication and had offered additional support to the service. Those offers were not taken up. The agreed facts also recorded that the nominated supervisor appointed earlier that year had not received specific training or competency assessment in managing the child's medical condition.

The Tribunal also found the provider breached regulation 93(1) because medication was not administered in accordance with regulation 95.

The child's medical management plan required medication to be administered 15 minutes before lunch. Instead, it was administered while lunch was being served. In addition, the educator's dosage calculations were not independently checked by a second person, despite this being required under both the child's medical management plan and the National Regulations.

A further breach of regulation 170(1) arose because the provider failed to take reasonable steps to ensure educators followed the service's policies and procedures relating to children's medical conditions. The Tribunal found the service had not continuously assessed staff understanding or implementation of those policies in practice.

Following the incident, the Department of Communities issued an Emergency Action Notice requiring the service to implement measures to remove or reduce immediate risks to children's safety, health and wellbeing.

The Tribunal noted that Goodstart complied with the notice within the required 14-day period.

As part of the agreed settlement, Goodstart acknowledged the seriousness of the incident, accepted responsibility for the contraventions and self-reported the incident to the regulatory authority.

The Tribunal also accepted that the provider maintained an established framework for medication administration before the incident and that the event occurred because existing controls were not followed on the day, rather than because appropriate systems were absent.

Following its internal investigation, Goodstart introduced a range of additional safeguards across its operations, including enhanced independent verification requirements, mandatory verbal cross-checking procedures, high-risk medication checklists, strengthened communication protocols, competency assessments for educators administering medication, quarterly medication audits and restrictions limiting the administration of high-risk medication to educators who have completed designated training. The Tribunal also noted that lessons from the incident informed improvements implemented nationally.

The Tribunal ordered Goodstart to pay:

• $28,000 for breaching section 167(1) of the National Law
• $1,800 for breaching regulation 93(1)
• $800 for breaching regulation 170(1)

In addition, the provider must contribute $2,000 towards the Department of Communities' legal costs. The amounts are payable within 30 days of an invoice being issued.

The decision reinforces that compliance with children's medical management plans requires more than documented policies and procedures. Approved providers are expected to ensure educators understand and consistently implement those plans, maintain effective verification and auditing processes, assess staff competency and respond appropriately when concerns are raised by families.

The case also highlights the importance of ensuring medication administration procedures remain robust in practice, particularly where children require high-risk or complex medications.

Read the full details on the eCourts Portal of Western Australia here.