Expand Menu Close Menu
Telephone: 1800 677 342

Occasional Paper No. 3

11th October 2021

Occasional Paper No. 3: Learning from reviews of Victorian disability service provision to people who have died 2017 to 2021 – A reflection for future safeguarding.

This report provides an overview of the lessons learnt from more than three years of reviewing disability service provision to people who have died.

Reviewing and investigating these services at the time of a person’s death provides a significant insight into their life, and their personal story. Our reviews tell us that some people do live good lives, and their disability services enhance and empower them to engage meaningfully in all aspects of their community. However, while some people’s deaths may be ‘expected’, the quality of service provision may not have been good enough. Sadly, the majority of deaths we review are ‘unexpected’ and raise significant concerns about the quality of service provision, possible preventable early deaths, and teach us that oversight and action must continue to be taken on both an individual and system-wide level.

In reviewing and investigating deaths, the DSC has learnt significant lessons regarding what we have done well, what we would do differently, opportunities we have missed, and opportunities and risks for the future. These lessons have informed eight recommendations and four potential gaps:


  1. Key partnerships
  2. Timeframes
  3. Workforce
  4. Data and information
  5. Compliance versus Continuous Improvement
  6. Quality of life analysis
  7. Continuity and co-design in Victoria
  8. Primary prevention

Potential gaps:

  1. Opportunity gaps
  2. Oversight gaps
  3. Information gaps
  4. Systemic gaps

Learning from reviewing Victorian disability service provision to people who have died will not cease completely with all in-kind providers transferred to the NDIS and NDIS Commission.  The DSC expects to continue this role in Victoria, on a very reduced scale, until such time as the Disability Act 2006 is amended and any proposed Social Services Regulatory Reform is undertaken.

View Occasional Paper No. 3: Learning from reviews of Victorian disability service provision to people who have died 2017 to 2021 – A reflection for future safeguarding here.

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