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Review into deaths of people with disabilities 2018-19

Image of the front cover of the 2018-19 Annual Reports.

8th November 2019

Our 2019 Annual Report, including A review of disability service provision to people who have died 2018-19 was recently tabled in Parliament.
The review is our first to cover an entire year and details the results of 38 investigations into the quality of care provided to people with disability who have died, completed in 2018-19. This data adds to the 11 months of data from matters investigated in 2017-18, with a total of 188 deaths reported over the two years, and 58 completed investigations.

The recent review identifies significant issues of concern consistent with 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 assessments and 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  • poor record keeping by disability services, including missing and illegible case notes as well as inaccurate and outdated information, resulting in gaps in critical information.

It is essential that these significant issues and failures in disability services be addressed as a matter of urgency as the link to potentially preventable deaths of people with disability must be prioritised.

The review and Annual Report are available on our website, or in hard copy via our resources page.

I must emphasize that these outcomes are relevant for everyone, not just those subject to our investigations.

Providers play a vital role in empowering people with disability to live safe and fulfilling lives; an aim we share. I sincerely hope that service providers will respond to this report by increasing their focus on identifying and implementing appropriate supports for the people receiving their services.

Cover image of the DSC 2018-19 Annual Report 

Level 20, 570 Bourke Street,

Melbourne, Victoria, 3000 Australia

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Email for enquiries or complaints - complaints@odsc.vic.gov.au