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Notice of Advice

21st March 2022

The following letter was sent electronically to Victorian registered disability service providers by Treasure Jennings, the Disability Services Commissioner, on 21 March 2022.

Dear CEO and quality team,

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

Practice Issue: Recording and monitoring of modified diets for people with dysphagia/swallowing difficulties

I write to provide you with a Notice of Advice pursuant to s.17(1)(da)(i) of the Disability Act 2006, in your capacity as a registered provider of disability services under the Disability Act 2006.

This advice relates to practices within Victorian disability services that could place people with disability at risk of health complications or death due to poor management of swallowing difficulties.

At the request of the Minister for Disability, Ageing and Carers, we undertake inquiries and investigations into expected and unexpected deaths reported to our office by the Department of Families, Fairness and Housing or the State Coroner. The objects of these inquiries and investigations are to:

  • understand any issues in the provision of services
  • consider any actions that services could take to address these issues
  • ultimately improve the provision of disability services.

As this is our fifth year of undertaking reviews into deaths of people with disability, we understand that many of the systemic practice issues previously identified are often inextricably linked.

In 2018, we issued a Notice of Advice <https://odsc.vic.gov.au/2018/11/26/notice-of-advice-systemic-issues-arising-from-the-review-of-disability-service-provision-to-people-who-have-died/>  to the sector in relation to the following four key practice areas that required immediate attention:

  • mealtime support
  • rights to communication
  • record keeping
  • absence of quality health plans.

We acknowledge that progress has been made by service providers, however these practice issues remain an ongoing concern and have been the subject of research, resources, practice standards and guidance across the State and Federal disability sectors (please refer to a list of relevant resources below).

I urge you to give consideration to this information and act accordingly, to improve health outcomes and prevent avoidable or premature deaths in people with disability.



In addition to the guidance that exists, we have identified the following critical area requiring immediate attention by disability service providers to improve health outcomes of people with disability:

  • recording and monitoring of modified diets for people with dysphagia/swallowing difficulties.

Mealtime support is a complex responsibility which can have serious consequences for people’s health and well-being. Since commencing investigations into the deaths of people with disability, respiratory diseases, mainly as a result of aspiration, have been the leading cause of death each year.

Providing quality supports and services in a safe and competent manner requires a considered approach, and this is particularly crucial in relation to mealtime support.



We consider that support can be improved for people who have swallowing difficulties and associated mealtime requirements for a texture-modified diet through proactive recording and monitoring of the type and texture of food provided.

Our experience in reviewing the deaths of people in receipt of disability services has shown that the texture of meals provided is rarely recorded by disability support workers and usually only when a medical or allied health professional has requested this.

Through routine recording by disability support workers of the type and texture of food, house supervisors and/or senior management can monitor adherence to individuals’ mealtime support plans. In so doing, there is the opportunity to potentially prevent illness such as aspiration pneumonia or choking events that can have catastrophic consequences. Existing food and fluid charts can be modified for the recording of the type and texture of food and drinks, and a process undertaken for regular checking by a supervisor or manager.

A mechanism for routine recording and monitoring will:

  • focus the attention of disability support workers on the texture requirements of people on modified diets
  • enable prompt identification of incorrectly prepared food so that improvement measures can be implemented in a timely manner.

We consider that this single practice change has the potential to significantly improve the quality of service provision and increase the health, safety and wellbeing of individuals with dysphagia/ swallowing difficulties.

We encourage you to work on this important issue to embed safe support practices and continuous improvement in the quality of services provided to people with disability.


Research, resources, practice standards and guidance across the State and Federal disability sectors


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