Review Reveals Significant Failures in Disability Service Provision

The Victorian disability services commissioner is urging providers to ensure they have systems in place to care for vulnerable people, after a review uncovered significant failures by some providers to protect the safety of people with disability.

Commissioner Arthur Rogers’ review into the deaths of people in disability care examined the cause, or preliminary cause of death for 48 cases in Victoria across 2017-18.

The review found some Victorian disability service providers were not meeting their legal duties to uphold the rights, safety and wellbeing of their clients.

Among the major concerns were a high number of cases where expert advice about implementing modified diets was not followed by providers, and poor record keeping which created critical information gaps preventing staff from providing appropriate support.

The preliminary cause of 10 deaths reviewed was choking on food or aspiration pneumonia – a life-threatening but often avoidable infection caused by inhaling food, fluid, saliva, or vomit into the lungs.

Rogers told Pro Bono News a lack of adequate professional assessments from providers could bring about these choking deaths.

“It can create some really dire consequences and potentially death for some people who may choke if they’re given the wrong food,” Rogers said.

Gaenor Dixon, the national president of Speech Pathology Australia, said the most common factors in choking deaths were a lack of personalised information about safe eating and drinking for people with disability, and insufficient supervision.

“People with disability need to have access to speech pathology services, who can work with individuals and also with the service to ensure safe eating and drinking and communication access for all,” Dixon said.

The review noted the case of a 72-year-old woman with cerebral palsy who died of aspiration pneumonia in July 2017.

The commissioner’s investigation found the woman’s swallowing difficulties were poorly managed by her disability service provider.

While she needed her food to be provided in a soft consistency because of her swallowing difficulties, she was instead given foods such as fish and chips, barbecued meat, sandwiches and cake.

“Case notes regarding [her] nutritional intake were found to be minimal and the records that were kept indicated she was provided with foods inconsistent with the advice of her speech pathologist and dietitian,” the review said.

Rogers said when there were known risks for a particular group of people with cognitive disabilities, it was essential providers actually followed a process to get the right assessment and ensured staff at all times were aware of these risks to manage them.

He called on service providers to ensure they always had the right support and processes in place to protect vulnerable people when risks had been identified.

“These are pretty basic safety precautions but we found they don’t always exist,” he said.

As a result of the review, Rogers has issued Notices to Take Action to a number of disability service providers to fix practices that did not meet their duties under the Victorian Disability Act, and notified Victoria Police and the State Coroner about concerns in individual cases.

“These outcomes are relevant for all disability service providers, not just those subject to our investigations. They will inform the refinement of planning and practice approaches and safeguarding arrangements as the disability sector transitions to the full roll-out of the National Disability Insurance Scheme,” Rogers said.

While he would not comment on if a royal commission into the disability sector was needed, Rogers said it was important there were regular reviews that shone a spotlight on the ongoing issues in disability services.

“I have written to providers and alerted them to the issues and I look forward to working with them to make sure that the right response is carried out this year and onwards,” he said.

Pro Bono News has reached out to service provider peak body National Disability Services for comment.