When her 11-year-old son Alex died almost five years ago, Sharon Braverman said she lost her life's purpose.
"It's worse than anything I can imagine … the pain is just underneath the rage and the feeling of injustice," she said.
"I was meant to be Alex's carer for the rest of my life … he was a gift to me, and anyone who knew him absolutely adored him."
Ms Braverman now lives with post-traumatic stress disorder and spends much of her time at her Sydney home, where she's surrounded by reminders of her son.
Alex's bedding has not been changed since the day he died. Ms Braverman often sits among his pillows and soft toys to feel close to him.
Ms Braverman hasn't taken Alex's calendar off their fridge. The handwritten schedule details the week he died.
The chicken pasta Ms Braverman made for Alex remains in the freezer.
Ms Braverman finds comfort in shining a torch onto Alex's handprints, which she hasn't cleaned off the wardrobe mirrors.
Sitting in the dark, she reflects the marks onto the ceiling and walls.
"This place is a museum of Alex," Ms Braverman said.
"I can't see him anywhere, but I can see him everywhere."
'I couldn't imagine anything worse'
Alex Raichman was diagnosed with autism and an intellectual disability at 20 months old.
A National Disability Insurance Scheme (NDIS) participant, he was assessed as needing one-to-one care at all times.
Alex was non-verbal and required his mother's constant attention, care and love.
"I never saw him as a disabled person," Ms Braverman said. "He was Alex and his autism was a really beautiful part of him."
As Alex got older and stronger, Ms Braverman could no longer take him to the car or even a playground by herself.
"He needed a whole team of really, really skilled people to make sure he was comfortable and safe," she said.
In April 2018, Ms Braverman and her husband Dale Raichman, along with Alex's twin brother, travelled to Melbourne to visit relatives.
"It wouldn't have been possible to take Alex with us," Ms Braverman said.
They entrusted Alex's care to a respite home they had used before, in Oatley in Sydney's south, run by Civic Disability Services.
"My expectation was a safe care setting, run and maintained by professional, skilled staff," Ms Braverman said.
Civic Disability Services is a not-for-profit organisation and registered charity founded in the 1950s. A registered NDIS provider, it has more than 800 employees who provide services to more than 700 clients with disabilities.
Alex was booked to stay at the house in Oatley for five nights while the family was away.
Ms Braverman informed Civic that her son was a "profound absconding risk" and he was assessed as requiring one-to-one care at all times.
On Alex's first night in the house, he attempted to escape through a window.
A Civic support worker emailed management expressing concern for Alex's safety and requested immediate work to secure the windows.
The next morning, Alex got out of his bedroom window and played outside for an hour.
Ms Braverman wasn't informed about Alex's attempts to escape.
"I would have been beyond horrified … I would obviously have been on the first plane back," Ms Braverman said.
The support worker sent another email to Civic regarding the lack of locks on the windows and a handyman attended the house to make them safe.
But the ensuite window wasn't secured and on the fourth night of his stay, Alex escaped. He jumped over a low-lying fence and ran from the house.
Following Alex on foot, a support worker called emergency services and hailed a passing police car.
As they searched the neighbourhood, Alex ran to Oatley railway station where he was last seen on CCTV on the platform at 7:23pm.
Alex walked onto the tracks and died instantly when he was hit by a train.
The shock of Alex's death is something his father cannot describe.
"I couldn't imagine anything worse for a family. It is very challenging to get through each day," Mr Raichman said.
"My main concern is for Sharon and whether she can ultimately move forward in some way."
'Betrayed trust'
Ms Braverman requested a coronial inquest and a 10-day hearing took place in April last year.
The findings were handed down by NSW deputy state coroner Harriet Grahame in October.
"Alex's family will never stop grieving and I acknowledge their ongoing pain," Magistrate Grahame said.
"The trust they placed in Civic to care for their precious child was betrayed.
"His death was entirely preventable if adequate safety measures had been in place."
Magistrate Grahame said the "deficiencies" in Alex's care included "inappropriate staffing levels".
"Civic had been fully informed of the risks inherent in housing a child such as Alex in a property with a low fence and unsecured windows."
Magistrate Grahame described the decision not to rectify the side fence at the house as "inexcusable" with "devastating consequences."
"Civic clearly failed in its duty to Alex and his family and all staff working with Alex," she said.
While Magistrate Grahame said the "deficiencies" in Alex's care were not caused by "the failings of a single person", Civic "as a whole, led by the CEO Annie Doyle, must take responsibility".
"I was very troubled by Ms Doyle's evidence, particularly her acknowledgement that Civic always knew that Oatley was a substandard property."
Magistrate Grahame did not make recommendations for any individual to be considered for criminal charges as a result of Alex's death.
The coroner's report made a number of recommendations which Civic has adopted, including no longer providing respite care to children under 16 years of age.
In a statement to the ABC, Civic expressed "genuine sadness" in relation to Alex's death and the "ongoing grief it has caused his loved ones".
"Since 2018, Civic has been committed to the full involvement in internal and external reviews to ensure we learned from this tragic accident," it said.
The statement said those reviews had "delivered systemic improvements" to the way Civic assessed support needs and managed risks.
"It remains the only incident of its type in Civic's 62-year history of providing care and support for people with disability, and we still mourn Alex's death today."
Ms Doyle has been called as a witness to appear at this week's disability royal commission hearing into disability service providers.
'His life meant absolutely everything'
While Ms Braverman was pleased with the coroner's findings, she remains heartbroken by the knowledge Alex's death was an "enormous and completely preventable tragedy".
She has taken Alex's case to the NSW Ombudsman, SafeWork NSW and the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability.
Despite her efforts, Ms Braverman feels the response to her son's death has been inadequate.
"There's been no accountability and it was just like, 'Well Alex died, oh well, that's sad.'
"Alex's future and his life meant absolutely everything to me."
Ms Braverman can't bring herself to remove the reminders of Alex around their house.
"Everything's now dusty and the trampoline has rust on it … I find it hard to change anything when he's supposed to be here."
The trampoline — as well as the chicken pasta, calendar, toys and handprints on the mirror — are ever-present memories of five years ago and Ms Braverman's expectation he would return home.
"He's been taken away from me, so all I've got left is his things and the things that were special to him," she said.
"I don't accept the universe without Alex being alive."
