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Information Sheet 9 Oversight of major impact incidents

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The Disability Services Commissioner (DSC) inquires into and can decide to investigate Category One/Major Impact incidents relating to abuse, neglect, injury and poor quality of care that occur in Victorian disability services. The aim is to improve services for people with disability and promote their wellbeing, health and safety.

How does DSC receive information about an incident?

DSC receives incident reports relating to abuse, neglect, injury or poor quality of care that occur in Victoria’s disability services from the Department of Health and Human Services (DHHS), after they have been submitted to DHHS by a disability service provider.

What does DSC look for when they inquire into an incident?

When DSC inquires into an incident, we consider factors such as:

  • The nature and quality of supports provided to the person or people with a disability before and after the incident occurred.
  • Any internal or external investigations conducted and their outcomes.
  • If any staff performance issues have been identified, investigated and addressed.
  • Whether policies and procedures such as DHHS Critical client incident management instructions and the Client incident management guide have been followed.
  • Whether the incident was reported to relevant entities such as Victoria Police and the Disability Worker Exclusion Scheme (DWES).
  • Whether a Quality of Support Review, Case Review or Root Cause Analysis or similar has been conducted, and if advice or recommendations have been implemented.

What can DSC ask for when inquiring into an incident?

DSC can speak to the service provider and/or DHHS and ask for further information or documentation. This might mean asking questions such as:

  1. Has the person involved in the incident received medical attention or other external supports (e.g. a referral to a Centre Against Sexual Assault)?
  2. Has the person’s family or other supports been notified of the incident so they can also provide support?
  3. How have other people with a disability who witnessed the incident been supported?
  4. Have behaviour support plans and other support documentation been reviewed?
  5. Have all staff members, not just those involved in the incident, been provided with additional training?
  6. Have there been internal or external investigations into the incident, and what were the outcomes?

During an inquiry, a service provider can respond to DSC requests but is not compelled to do so.

What happens after an inquiry?

DSC may provide comments on what steps a disability service provider should take to improve the provision of disability services including ways to address the health, safety, and wellbeing of people with a disability involved in the incident. The Commissioner may also decide to investigate any incident report received.

What does a service provider have to do after DSC has made the decision to investigate?

DSC may decide to conduct an investigation into an incident report which allows DSC to use additional powers to compel evidence and inspect the premises of disability service providers.

Disability service providers need to provide reasonable assistance to DSC investigations. This may include providing information and documents, attending interviews, and allowing DSC Authorised Officers access to disability service premises for inspection.

There are various protections available for people who give information or documents during an investigation. Information provided in good faith will not constitute unprofessional conduct or a breach of professional ethics and the person will not be liable for disclosure of information.

What happens after an investigation?

After an investigation, DSC will notify the disability service provider of the decision and reasons for decision. DSC may also decide to issue the service provider with a Notice to Take Action. This notice will outline the actions the disability service provider should take to improve the services investigated.

DSC must also provide an investigation report to the Minister of Disability, Ageing and Carers and the Secretary to DHHS.

If the report contains adverse comments or opinions about the disability service provider, DSC will give the service provider at least 14 days to respond before the report is sent to the Minister and Secretary to DHHS.

Why is DSC conducting inquiries and investigations?

The then Minister for Housing, Disability and Ageing requested that DSC conduct inquiries, and at his discretion, investigations into Category One/Major Impact incidents related to Victorian disability services as part of a referral made in September 2017.

DSC advice and recommendations can help drive change that improves both individual service providers and the disability sector as a whole.

Contact Us

Phone (preferred): 1800 677 342 (free call from landlines) or TTY 1300 726 563
Website:  www.odsc.vic.gov.au
Fax:
03 8608 5765
Email:  ODSCReview@odsc.vic.gov.au
National Relay Service: www.relayservice.gov.au then 1800 677 342

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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