A culture of fear within Victoria's disability sector and an archaic system that asks people to report abuse via fax means the state's most vulnerable are constantly overlooked.
A reluctance to report mistreatment and a lack of urgency in trying to stop it were noted in the Victorian Ombudsman's second report into abuse in the disability sector, released on Wednesday.
People with disabilities and their families are often too scared to report abuse because they are worried they will be banned from using crucial services.
Under-reporting is further exacerbated by a system of incident reporting that fails at every level, the report says.
A reliance on fax machines reflects an "archaic" approach, the ombudsman's report says.
Victims are sidelined during investigations when they should be prioritised.
"What we found was that the person at the centre of an incident - the person with disability - is largely absent," Victorian Ombudsman Deborah Glass said on Wednesday.
Disability workers are reluctant to report seeing abuse because they are worried about intimidation from colleagues and managers.
In one instance, several workers at a home had seen a senior staff member twice abuse a resident, resulting in a broken leg the first time and a broken kneecap several months later.
The abuse was later reported anonymously, with the worker saying staff were afraid of retribution.
One father told the inquiry he was not confident disability workers know how to identify abuse.
"I'm tired of needing to educate government authority around what constitutes abuse," he said.
The ombudsman has made 13 recommendations, including mandatory reporting of abuse in the disability sector.
The review was sparked by reports in 2014 that disability service provider Yooralla continued to employ abusive or corrupt staff despite warnings they preyed on disabled clients.
The community services sector says too many people with disabilities are subjected to abuse and neglect and it's time that culture changed.
"It is paramount that we enshrine strong advocacy for people with disability at the heart of the service system," said Mary Sayers, the deputy chief of the Victorian Council of Social Service.
