20th December 2018
Our 2018 annual report and review of disability service provision to people who have died 2017–18 was tabled in Victorian Parliament yesterday.
The review is our first ever. It reveals significant failures by some disability service providers to meet their obligations under the Disability Act 2006 (the Act). I had previously highlighted a number of the concerns in a Notice of Advice sent to all Victorian disability service providers in November 2018.
With assistance from the Coroners Court of Victoria, we have obtained information about the cause or preliminary cause of death for 48 of the 88 deaths that were in scope for our review.
The preliminary cause of death for three of the 48 deaths was attributed to the person choking on food and a further seven deaths to aspiration pneumonia, a life-threatening but often avoidable infection caused by inhaling food, fluid, saliva or vomit into the lungs.
Our major concerns include:
- A number of cases in which expert advice about implementing modified diets was not followed by the disability service, placing people with disability at significant risk of health complications or death.
- A lack of communication assessments and communication plans to support people with a disability to communicate their specific needs, notify others of their deteriorating health, and exercise choice and control over their lives.
- Poor record keeping by disability services, including missing and illegible case notes and inaccurate and outdated information, resulting in gaps in critical information to ensure that all staff provide appropriate and safe support. While some had good policies and procedures, they were not consistently followed.
- Half of the people whose deaths may be related to heart conditions had not seen either a cardiologist or dietitian in the previous year.
The review and a snapshot of findings are available on our website. We will also send a hard copy of the Review to all disability service providers registered under the Act.
As a result of our investigations, we have issued advice on systemic reform to the Department of Health and Human Services (DHHS), issued Notices to Take Action to some disability service providers to rectify practices that did not meet their obligations under the Act, and notified Victoria Police and the State Coroner about concerns in individual cases.
In November 2018, we issued a Notice of Advice to all Victorian disability service providers.
I must emphasise that these outcomes are relevant for all disability service providers, not just those subject to our investigations. We expect service providers to respond to this report by increasing their focus on identifying and implementing appropriate supports for the people they are supporting.
I also encourage people with disability, their friends and family, and staff in disability services to check that the right support is being provided and to raise any concerns they may have.
Disability Services Commissioner