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Review of disability service provision to people who have died

On 12 September 2017, the Minister for Housing, Disability and Ageing requested that the Disability Services Commissioner inquire into and, at the Commissioner’s discretion, investigate the provision of disability services for Victorians in receipt of disability services at the time of their death.

On 25 June 2021 the Honourable Luke Donnellan, Minister for Child Protection and Minister for Disability, Ageing and Carers (The Minister) issued an extension of the 2020 referral that requested that DSC inquire into and, at the Commissioner’s discretion, investigate any matter relating to the provision of services (including abuse or neglect in the provision of services) by disability service providers within our jurisdiction until 30 June 2021. The Minister made the referral under section 128I(2) Disability Act 2006 (Act). The referral (available below), replaces previous referrals except with respect to matters outstanding under those referrals. This referral is to take effect from 1 July 2021 until 30 June 2022.

We conduct our  investigations into disability service provision to people who have died under s.128I of the Disability Act 2006 (Vic) (the Act).

The inaugural review conducted by the Disability Services Commissioner was tabled in Victorian Parliament on Wednesday 19 December 2018. This work has not previously been performed in Victoria.

A review of disability service provision to people who have died 2018-19

The review is our first to cover an entire year and details the results investigations into the quality of care provided to people with disability who have died, completed in 2018-19. The recent review identifies significant issues of concern that mirror many of our inaugural 2017-18 report findings.

Our major concerns include:

          • the number of cases in which assessment and support plans about mealtime support were not followed by the disability service
          • the lack of communication assessments and communication plans to support people with a disability to communicate their specific needs, and exercise choice and control over their lives
          • poor management of health conditions, especially bowel management and managing deteriorating health
          • poor record keeping by disability services, including missing and illegible case notes and inaccurate and outdated information, resulting in gaps in critical information to ensure that all staff provide appropriate and safe support, and
          • inconsistent application of policies and procedures.

Download A Review of disability service provision to people who have died 2018-19  (PDF 808 KB)

Download A review of disability service provision to people who have died 2018–19 (RTF 398 KB)


A review of disability service provision to people who have died 2017-18

During 2017–18, we received notifications from the Department of Health and Human Services (now DFFH) and the State Coroner of deaths of people with disability.

Of these:

  • 88 deaths were in scope for investigation.
  • Half of those deaths investigated related to people receiving disability services from the Department of Health and Human Services, and half from non-government disability service providers.
  • Of the 88 investigations commenced, 20 investigations were completed in the seven months since the Commissioner commenced the review under newly provided powers.
  • 10 completed investigations resulted in adverse findings about the service provider and either a notice to take action or advice was issued to rectify practice deficits including: swallowing and choking risks, health plans, bowel management, record keeping and incident reporting, duty of care training, the need to promote healthy eating and physical activity and the effective administration of medication.
  • Advice and recommendations were made to the Secretary to DHHS in her role as funder and regulator of Victorian disability services, as a consequence of significant practice deficits identified in two completed investigations.
  • Most deaths (83%) involved people with disability who resided in shared supported accommodation.
  • Eight of the ten people whose preliminary cause of death was either choking or aspiration pneumonia were people with an intellectual disability.
  • Many people were not afforded their right to be able to communicate. For example, 11 of 35 (31%) people described as being non-verbal but able to communicate with aids or gestures were not provided with a communication plan by their disability service provider.
  • Median age of death was 52 years for males and 54 years for females – 29 years less than the median age at death for the general Australian population.
  • Analysis of the practice issues identified in completed investigations is consistent with findings in the literature and in reviews conducted by other jurisdictions in Australia and the United Kingdom.


Review of disability service provision to people who have died 2017-18  (PDF 753KB)
Review of disability service provision to people who have died 2017-18  (DOC 389KB)

Actions required

The outcomes of this work are relevant for all disability service providers, not just those subject to our investigations and Notices to Take Action.

The report should inform the implementation of the NDIS, particularly with a focus on appropriate assessment and planning for people who require communication, dietary or mealtime assistance.

We also expect all service providers to respond to this report by increasing their focus on identifying and implementing appropriate supports for people with disability receiving their services.

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