NDIS Commission begins legal action against care provider after 'tragic' death in group home

The NDIS Quality and Safeguards Commission has commenced civil penalty proceedings in the Federal Court against an ACT care provider after a group home resident who was required to eat only soft food died choking on a toasted sandwich.

According to the concise statement filed by the NDIS Commission, the 47-year-old man known as ‘Mr H’, who was non-verbal, had an intellectual disability, autism, type 2 diabetes and Prader-Willi syndrome, died while in the care of Valmar Support Services Limited at a residential group home at Hemmings Crescent in Richardson.

Valmar is a registered NDIS provider and provides disability, aged care and community transport services in the ACT, Riverina/Southwest Slopes and Southern Tablelands.

It is alleged that two other residents at Hemmings, known as Mr K and Mr I, were also put at serious risk of harm by Valmar from 11 September 2018 to 14 May 2020 due to deficient implementation of mealtime management and dietician plans.

The NDIS Commission said in a statement it would also claim that Valmar employed staff without the necessary accreditation or training to provide support and services in a safe and competent manner, with due care and skill.

The concise statement said Mr H’s mealtime management plans prepared by an accredited dietician in 2016 specified that he did not chew food, was at risk of choking and had to be given soft food.

However, it said the dietician’s services were terminated in 2018 and a new dietician was not engaged before 2020, despite requests from Mr H’s guardian(s) to do so.

The statement said that in 2019, a Valmar employee prepared a meal and snack management plan for residents of Hemmings as a guide for other employees.

However, the plan allegedly failed to record that Mr H’s food “must be soft, cut into bite-sized pieces, and moist”, as well as offering other inconsistent advice for Mr H, Mr K and Mr I.

According to the statement, there was no menu plan or shopping plan in place at Hemmings, nor was there supervision or a safety audit concerning compliance of Mr H’s eating and drinking plans.

“On many occasions, workers provided Mr H and Mr K with food that did not comply with the requirements of their eating and drinking plans … thereby exposing Mr H, Mr K and Mr I to the risk, alternatively the increased risk, of choking on their food,” it said.

“At about 12:20 pm on 14 May 2020, Mr H choked and collapsed while eating a salami and cheese toasted sandwich at Hemmings,” the concise statement said.

“The toasted sandwich … was not soft, or moist or cut up into bite-sized pieces.”

The statement said the member of staff who gave Mr H the sandwich called Triple-0 and commenced CPR until paramedics arrived. Mr H remained unconscious and died.

The NDIS Commission will argue that Valmar failed to comply with the NDIS Code of Conduct and Practice Standards.

“Valmar’s failure to provide services to each of Mr H, Mr K and Mr I in accordance with the conditions of its registration as an NDIS provider caused harm of the utmost seriousness to those persons of disability who, by virtue of their disabilities require protection from harm. For Mr H, Valmar’s failures resulted in his death,” the statement said.

NDIS Quality and Safeguards Commissioner Tracy Mackey said the death was “tragic” and that in the most serious cases like this, the NDIS Commission would take strong action such as banning workers or providers, de-registering providers and seeking civil penalties.

“NDIS providers have very clear obligations. Failures, like those alleged by the NDIS Commission in these proceedings are unacceptable, and require the strongest regulatory response,” she said.

“We will use our power to investigate any matters relating to any NDIS provider and workers where the provider has failed to deliver supports and services in a safe and competent manner with care and skill.”

Original Article published by Lizzie Waymouth on Riotact.