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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 28 June 2019, the Minister for Disability, Ageing and Carers (the Minister) extended the referral until 30 June 2020, in recognition that there remain people with disability in Victoria that are yet to transition to the NDIS and still receive disability services funded by the Department of Health and Human Services (DHHS).

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.

Download the report

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)

Download the key themes and implications

This is a supplementary document produced for the 2019 National Disability Services Victorian State Conference.

Download report in Plain English

Review of disability service provision to people who have died 2017-18 in plain English  (PDF 218KB)

Review of disability service provision to people who have died 2017-18 in plain English  (html)


For more plain English information visit www.odsc.vic.gov.au/resources/plain-english-resources/ 


Snapshot of findings

During 2017–18, we received notifications from the Department of Health and Human Services (DHHS) 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.

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 20, 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