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Telephone: 1800 677 342

Notice of Advice

26th November 2018

Note – this letter was sent electronically to Victorian disability service providers by Arthur Rogers, the Disability Services Commissioner, on 21 November 2018.


Dear CEO of <Organisation>,

Notice of Advice: Systemic issues arising from the review of disability service provision to people who have died

I write to provide you advice[1] in your capacity as a provider of disability services under the Disability Act 2006.

This advice relates to practices occurring within Victorian disability services that could place people with disability at risk of health complications or death.

At the request of the Minister for Housing, Disability and Ageing, we undertake inquiries and investigations into expected and unexpected deaths reported to our office by the Department of Health and Human Services or the State Coroner. The object of these inquiries and investigations is to understand any issues in the provision of services; to consider any actions that services could take to address these issues; and to ultimately improve the provision of disability services.

Through this work to date, we have identified the following critical areas requiring immediate attention by all disability service providers:

  1. The imperative for disability service providers to seek and implement expert advice to safely support people with a disability, particularly in relation to mealtime assistance. We have for example, observed instances where either people were not assessed in relation to their risk of choking, or where expert advice about implementing modified diets was not followed by the disability service, thereby placing people with disability at significant risk.
  2. The importance of supporting people’s right to communicate in a manner appropriate to their needs. Our analysis of the cases reported to us over the past year has indicated 31 per cent of people who were described as being non-verbal, but able to communicate with aides or gestures were not provided with essential communication plans or aides. This failure has a direct impact on the ability of people with disability to communicate their specific needs, for example, being able to notify others of their pain, distress or deteriorating health. This in turn can often increase the risk of health symptoms being missed and/or of their behavior being misinterpreted as requiring behavioral support, masking potentially serious health risks.
  3. The need to ensure quality record keeping. We have observed many examples of missing or illegible case notes and inaccurate and outdated records. This has resulted in gaps in critical information necessary to ensure that all staff are able to provide appropriate and safe support.
  4. The absence, or poor quality, of health plans resulting in adverse outcomes for people receiving services. Our investigations identified instances when people with significant health issues either did not have a health plan, the plan was not up to date or the plan was not being followed by staff. In five investigations, service providers were required to review all of the health plans for people at their supported accommodation facilities to ensure that their health needs are documented, and that an associated health plan for each diagnosed condition was developed in conjunction with the person’s doctor and subsequently reviewed regularly.

DSC staff will be presenting at the NDS Quality and Safeguarding Forums to be held in November / December of this year, on the key findings and issues arising from our review of disability service provision to people who have died.

I have also written to the Secretary of the Department of Health and Human Services and the CEO of the National Disability Insurance Agency to bring these issues to their attention.

I look forward to working with you on these important issues over the coming year to improve the safety and wellbeing of the people with a disability that we all serve.

Yours sincerely,

Arthur Rogers
Disability Services Commissioner

[1] Disability Act 2006, s.17(1)(da)(i).

Level 30, 570 Bourke Street,

Melbourne, Victoria, 3000 Australia

Call for enquiries or complaints - 1800 677 342

Email for enquiries or complaints - complaints@odsc.vic.gov.au