Last year, the Victorian government gave my office increased powers to investigate the quality of disability supports provided to people with disability in response to the 2016 Parliamentary Inquiry into Abuse in Disability Services.
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That inquiry reported widespread abuse and neglect of people with disability and shortcomings of essential safeguarding and oversight systems in Victoria.
At the specific request of the then Housing, Disability and Ageing Minister, one of my new functions is to inquire into and, at my discretion, investigate the provision of disability services to people who died whilst in receipt of those services.
We commend the state government for enabling us to provide this important new oversight for people with disability in Victoria.
Our inaugural report – Review of disability service provision to people who have died 2017-18 – released this week, has revealed significant failures by some providers to meet their obligations under the Disability Act 2006.
Those failures have been apparent in three areas in particular.
Firstly, in the support that people with disability get for mealtimes, to ensure that they can eat and drink safely.
Aspiration pneumonia – a life-threatening but often avoidable infection caused by inhaling food, fluid, saliva or vomit into the lungs – was of particular concern.
Some people with disability experience difficulty in swallowing food and drink and can be at risk of developing aspiration pneumonia. Last year, the State Coroner identified aspiration pneumonia as the preliminary cause of death for seven of the cases we examined. For a further three people, their preliminary cause of death was identified as choking on food.
The risk of people experiencing aspiration pneumonia is increased if people with disability are not given essential assessments, for example by speech pathologists, to investigate whether they have a compromised swallowing reflex, and to provide advice about how people can be best supported to eat and drink. In some cases that we investigated, having the assessment was no guarantee of good mealtime support as professional advice had not been followed by support staff.
Our second major concern was in the quality and level of support that people with disability get to communicate when they are not able to do so verbally or easily – an issue for many people with both or either physical and intellectual disabilities.
There were many cases we looked at where people with disability had no spoken communication but disability services had not done anything to make sure they could express themselves.
Health issues are too often not identified and therefore treated because people may not be able to communicate pain, distress, or symptoms. This in turn can often increase the risk of health symptoms being missed and/or of their behavior being misinterpreted as requiring behavioral support, masking potentially serious health risks.
Communication is fundamental to people’s rights, and to their health and well-being, and should be supported accordingly.
Our third area of concern related to the processes of disability service providers.
We found that some had good policies and procedures but did not always follow them. In some cases we found evidence of poor record keeping, including missing and illegible case notes and inaccurate and outdated information.
This can mean there are critical gaps in the information that staff should have so they can provide appropriate and safe support to people with disability.
We have not waited until the report was released to act on our concerns.
As a result of our completed investigations, we have issued eight notices to take action to service providers to rectify practice deficits relating to swallowing and choking risks, health plans, bowel management, record keeping and incident reporting, and duty of care training.
We have issued a notice of advice to all Victorian disability service providers on critical areas of concern requiring immediate attention. We have also notified Victoria Police and the State Coroner about concerns in individual cases.
Our investigations will continue until my office closes as part of the transition to the National Disability Insurance Scheme.
We believe our review should inform the rollout of the National Disability Insurance Scheme, particularly with a focus on appropriate assessment and planning for people who require communication, dietary or mealtime assistance.
We expect all disability service providers to check their systems and processes to make sure that they identify and implement the right supports for people with disability.
This is a wake-up call for Victorian disability providers which should resonate nationally.
Arthur Rogers is Victoria’s Disability Services Commissioner.