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Information Sheet 10 Investigating deaths in disability services

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The Disability Services Commissioner (DSC) inquires into and, at the Commissioner’s discretion, investigates the provision of disability services to people who were receiving these services at the time of their death.

What is DSC investigating and why?

DSC is examining the provision of disability services to persons who were receiving these services at the time of their death.

This means that both expected and unexpected deaths between 24 July 2017 to 30 June 2019 reported to the Department of Families, Fairness and Housing (DFFH) or the State Coroner are referred to DSC.

The goals are to identify any issues in the provision of services to the deceased person and inform improvements across the sector.

Does my organisation fall within this investigation process?

This investigation process applies to any disability service provider who meets the definition of ‘disability service provider’ or ‘regulated service provider’ in the Disability Act 2006.

This means that disability services provided by the Secretary to DFFH, persons and bodies registered on the register of disability service providers, contracted service providers, funded service providers and prescribed service providers will fall within this investigation process.

How will I know if DSC investigates my service?

Once notified by the State Coroner or DFFH, DSC will send a letter to the service provider notifying them of the commencement of an investigation.

What is the investigation process?

Investigations are conducted across two phases. Not all investigations proceed to the second phase.

Phase one routinely involves DSC requesting the service provider to complete and return a questionnaire and relevant documents about the provision of disability services to the person who has died. DSC will review this information and documentation. If DSC identifies issues of potential concern about the adequacy of services provided to the deceased person, or if there is information to indicate the likelihood of abuse or neglect, DSC will progress the investigation to a more comprehensive (phase two) approach.

A phase two investigation may include further requests for documents, interviews, site visits or hearings. DSC will communicate with the affected service providers about the further investigation and what may be required of them during this process.

What happens after an investigation?

After the completion of the investigation (whether at phase one or phase two), DSC will prepare a report for the Minister and the Secretary to DHHS. If the death meets the definition of a ‘reportable death’ in the Coroners Act 2008, we will also provide the report to the State Coroner.

If the report makes adverse comments or findings, the service provider or individual will have an opportunity to respond to these comments and findings before DSC finalises the report. These reports are not publicly available, however are subject to a Freedom of Information (FOI) request.

Each year, DSC will provide a comprehensive report of the deaths reviewed as part of its Annual Report. This report will outline the issues that have been identified from our reviews of disability service provision to people who have died.

This report will be publicly available but will not include any information that identifies an individual or entity. For more information, see our privacy policy at www.odsc.vic.gov.au/about-us/privacypolicy/.

What will my service have to do after an investigation?

In some cases, a Notice to Take Action may be issued to a service provider if issues of concern are identified. In previous cases, this has included actions like:

  • addressing swallowing and choking risks
  • improving the quality of health plans
  • safer bowel management practices
  • improving record keeping and incident reporting
  • duty of care training for staff
  • training for staff to support health and wellbeing of people with disability

DSC may also decide to conduct a follow-up investigation into actions taken by a service provider in response to the Notice to Take Action.

Contact Us

Phone (preferred): 1800 677 342 (free call from landlines)
Website:  www.odsc.vic.gov.au
03 8608 5765
Email:  DSCDeathReview@odsc.vic.gov.au
National Relay Service: www.relayservice.gov.au then 1800 677 342

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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