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Annual reports

2022-23 Annual Report 

The Annual Report including A review of disability service provision to people who have died 2022-23 details the work undertaken by DSC.

Download the 2022-2023 Annual Report (PDF 786 KB)

Download the 2022 – 2023 Annual Report – Accessible (DOCX 628 KB)

This report details the work undertaken by DSC, including:

              • 403 enquiries with information provided
              • 57 complaints assessed and 53 warm written referrals made
              • 5 new incident reviews
              • 25 finalised death investigation reports.

DSC issued two Notices of Advice this year. One was in relation to a complaint connected to community access hours funded by the TAC and the other was in relation to incident reporting and compliance with the CIMS guidelines.

This year was the DSC’s sixth annual review of disability service provision to people who have died in Victoria.  It includes details of the 24 closed investigations, and 1 finalised investigation report.

The top issues identified in our finalised investigations were:

  • managing specific health conditions
  • record keeping practices
  • communication supports.

We issued 10 Notices to Take Action in 2022-23. Importantly, in 11 investigations an NTTA was not required as we were satisfied that the service provider both identified issues of concern and had taken steps to address or would address these issues.

 

2021-22 Annual Report 

The 2021-22 Annual Report including A review of disability service provision to people who have died 2021-22 details the work undertaken by DSC.

Download the 2021-22 Annual Report (PDF 1382 KB)

Download the 2021 – 2022 Annual Report – Accesible (DOCX 4,589 KB)

This report details the work undertaken by DSC, including:

            • 455 new enquiries
            • 84 complaints handled
            • 53 finalised incident reviews
            • 12 finalised Community Visitor Board referrals
            • 53 finalised death investigation reports
            • 188 disability service providers submitted their Annual Complaints Report to the DSC.

A review of disability service provision to people who have died 2021-22

This year was the DSC’s fifth annual review of disability service provision to people who have died in Victoria.  The report includes details of our finalised investigations.

The key issues of concern in our finalised investigations were:

  1. Health management
  2. Service quality
  3. Record keeping and incident management.

We issued 13 Notices to Take Action in 2021-22.

This year we noted a strong commitment from service providers to engage with us in relation to service improvement, and we have also seen a steady increase in the number of quality and safeguarding teams now employed to support continuous improvement within disability support organisations.

 

2020-21 Annual Report 

The 2020-21 Annual Report including A review of disability service provision to people who have died 2020-21 details the work undertaken by DSC.

Download the 2020-21 Annual Report (PDF 931 KB)

Download the 2020-21 Annual Report (RTF 15462 KB)

This report details the work undertaken by DSC, including:

            • 553 enquiries
            • 103 complaints
            • 404 new incident reports
            • 91 finalised death investigation reports
            • 51 Community Visitor Board referrals.

 

 

A review of disability service provision to people who have died 2020-21

This year was the DSC’s fourth annual review of disability service provision to people who have died in Victoria.  It includes details of the 86 finalised and closed investigations, and 5 finalised investigation reports with a Notice to Take Action (NTTA) remaining open.

The key issues of concern in our finalised investigations were:

  • service quality – communication supports, mealtime supports, bowel management, behaviour supports
  • managing specific conditions – health plans, illness prevention and monitoring
  • managing deteriorating health
  • record keeping.

Importantly, in 23 finalised investigations the DSC found that disability services were provided in a manner that sufficiently promoted the rights, dignity, wellbeing and safety of the person who had died.  This demonstrates a consolidation of improved practice and a commitment from service providers to continuous quality improvement.

 

2019-20 Annual Report 

In December the 2019-20 Annual Report including A review of disability service provision to people who have died 2019-20 was tabled in Victorian Parliament.

Download the 2019-20 Annual Report (PDF 2374 KB)

Download the 2019-20 Annual Report (RTF 1469 KB)

This report details the work undertaken by DSC, including:

            • 912 Enquiries and complaints, including 750 enquiries and 162 complaints
            • 540 incident reports
            • 264 Death investigations
            • 17 investigations, including 8 initiated by commissioner, 6 referred from complaints and 3 referred from incident reports.

 

 

A review of disability service provision to people who have died 2019-20

Regrettably, in 2019–20 people with disability in receipt of disability services continued to be over-represented in deaths due to respiratory diseases and nervous system diseases (mainly epilepsy-related deaths) compared to the general population. This data aligns with research from other states and territories in Australia.

The top five causes of death as categorised by the ICD-10 were: diseases of the respiratory system (38%), diseases of the circulatory system (14%), diseases of the nervous system (13%), neoplasms (13%) and external causes (7%).

In addition to providing an overview of key health issues, the report highlights the issue of supported decision-making and how people with disability are not consistently provided with the support necessary to make, communicate, and participate in decisions that affect them.

In 2019–20, DSC received 134 new notifications of people with disability who died whilst in receipt of disability services; 62 of these death notifications were in-scope and 72 out-of-scope for the DSC.

It is important to note that there was a decrease in notifications of deaths in-scope for investigation in 2019–20, due to the reduction in our jurisdiction over 2019–20, and the commencement of the NDIS Quality and Safeguards Commission in Victoria.

In 2019–20, there were no notifications of deaths of people with disability due to COVID-19 that were in-scope for the DSC.

2018-19 Annual Report

Cover image of the DSC 2018-19 Annual Report In October the 2018-19 Annual Report was tabled in Victorian Parliament. This report details the work undertaken by DSC, including:

            • 1513 Enquiries and complaints, including 1101 enquiries and 469 complaints
            • 985 Incident reports, including 797 incident reports and 188 deaths reported
            • 59 presentations and information sessions reaching over 2,000 people
            • as well as completing and launching the Building Safe and Respectful Cultures (BSRC) project on abuse prevention.

Download 2018-19 Annual Report (PDF 1524 KB)

Download 2018-19 Annual Report (RTF 670 KB)

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 852 KB)

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

2017-18 Annual Report

With reflections on learning gained from the complaints brought to Disability Services Commissioner (DSC), the DSC Annual Report is a helpful resource for anyone wanting to gain an understanding of complaints about the Victorian disability sector.

Download 2017-18 Annual Report in PDF (2MB)

Download 2017-18 Annual Report in DOC (429KB)

 

 

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

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.

This is the inaugural Review.

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

Click here for more information.

 

Previous Annual Reports

2016-17 DSC annual report

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Download in DOC (858KB)

2015-16 DSC annual report

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Download in RTF (403KB)

2014-15 DSC annual report

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Download in RTF (362KB)

2013-14 DSC annual report

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2012-13 DSC annual report

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2011-12 DSC annual report

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2010-11 DSC annual report

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Download in RTF (870KB)

2009-10 DSC annual report

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2008-09 DSC annual report

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2007-08 DSC annual report

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