Poor risk management by care providers has been blamed for the potentially avoidable choking-related deaths of a number of disabled people in Victoria, a report reveals.
Three people in supported accommodation died after choking on food in 2017-18, while a further seven deaths were attributed to aspiration pneumonia, an infection which can be caused by inhaling food or fluid.
Police and the Victorian coroner have been notified about concerns in individual cases, while some providers have been urged to take action to improve safety, according to the Disability Services Commissioner.
An elderly woman with cerebral palsy who died the day after being diagnosed with aspiration pneumonia is one of the cases to be investigated by the body.
The 72-year-old lived in shared supported accommodation and required her food to be soft due to swallowing difficulties but was instead fed fish and chips, barbecued meat, sandwiches and cake.
The commissioner found she was provided with foods inconsistent with the advice of professionals and said her requirements were "poorly managed".
The case was uncovered by the commission in its first review into deaths in care after being granted the powers to do so by the Victorian government following an inquiry into abuse in disability services.
Information about the cause or preliminary cause of death was obtained for 48 deaths in the first seven months of its work.
"It is of significant concern that during the relatively short period we have been undertaking this work, there have been three cases reported to our office where the person's preliminary cause of death was choking on food," the report states.
The inquiries into deaths are ongoing but "poor management of swallowing and choking risks have been evident in a number of our completed investigations", the report states.
"Even where there has been expert advice provided by a dietician or speech pathologist about providing modified diets, we have found repeated examples of such advice not being followed, resulting in people with disability being placed at significant risk of health complications or death," it said.
Victorian Disability Services Commissioner Arthur Rogers said providers are failing the people they should be caring for.
"This important review tells us that some Victorian disability service providers are not meeting their obligations under the Act to uphold the rights, safety and wellbeing of people with disability," he said.
