The Victorian Services Commissioner has referred disability service providers to the police for possible criminal investigation over the deaths of people receiving disability care.
The report by the Victorian Disability Services Commissioner found 'significant failures' in the provision of disability services, which resulted in death in 2017-18.
Last year, the commissioner was given new powers to investigate the circumstances of the deaths, examining individual cases to gather a picture on the more systemic issues in the lapses of the quality of care provided.
Commissioner Arthur Rogers said the report confirmed the findings of a lapse in standards uncovered in a Victorian parliamentary inquiry last year, as well as international investigations into the same issue.
"I would like to see that there are zero deaths, unnecessary deaths, and that there are no instances of disability support that miss some of the basics around how they should support people at risk," Commissioner Rogers said.
"So even one unnecessary death is one too many."
Increased safety risk for those with intellectual disabilities
Of the 88 cases examined, half involved government service providers and the other half were non-government service providers.
People with intellectual disabilities were at a higher risk of dying from choking because of difficulties swallowing.
This was compounded by a lack of records of an assessment, support plan and communication plan. And in cases where they were available, there were instances of staff not following the plan.
"We also found that some providers don't have adequate health support and monitoring plans. And that would mean they are not always alert to some issues and their response to health issues would be slower than it would otherwise be," Commissioner Rogers said.
Police referrals for serious cases
Eighty-three per cent of the deaths occurred in shared accommodation. The median age of those who died was 29 years younger than the general population - 52 years for the male deaths, 54 for the female deaths.
Half of the people whose deaths may have been connected to an underlying heart condition had not seen a cardiologist or dietitian in the last year.
A number of disability service providers have been referred to Victoria Police and the State Coroner.
"Where we have thought the matter is beyond serious lapses in duty of care, it's a matter for the police. We would have notified the police. It is a matter for them of course to look at that.
"Similarly, where there are issues we thought the coroner might be interested in, we've referred them on."
Notices to Take Action have been issued to service providers who have contravened their obligations under Victoria's Disability Act 2006.
"In terms of the service providers, we've been very active in making sure that we take appropriate action with them in a timely way, so that they give us assurances and evidence that other people receiving their services are safe."
Call for separate Royal Commission
The Victorian Advocacy League for Individuals with Disability said the findings are disturbing and should prompt immediate action.
"I feel ill. I think anyone who looks through it [the report] that this has happened to our most vulnerable people.
"Families place their loved ones in care believing that they're going to get care. And this just highlights the fact that that is not always case. This is carelessness of the highest order."
Mr Stone said he believes the findings of the report merit a separate Royal Commission, aside from the inquiry that will kick off in February into aged care services with an added term of reference for people with disabilities.
Senator Jordan Steele-John breaks down as he pleads for inquiry into disability care
"What we want to see is a royal commission into the abuse of people with disabilities. And I think that might need to include the issue of neglect.
"I'm giving you my initial reaction to it [the report]. It is just highly distressing to see what's been going on in some of these services. And we need to do something about it."
Actor and advocate Chris van Ingen, who has cerebral palsy, said he supports that call.
"You have to remember that in the terms for references for the aged care Royal Commission the disability part was only tacked on after pressure from the community.
"And there are a lot more people with disabilities that are not part of the aged care system."
The report found that a number of deaths from people choking on their food had happened after expert advice on modified diets had been ignored by staff.
Mr van Ingen said he himself had choked on food because staff had been rushing and made mistakes in following the dietary requirements, but fortunately he had been able to communicate about his situation.
"There's not enough staffing levels [in the facilities]. So people have to rush. I am very capable of communicating my needs and there have been times when even I have been fed so fast that I have choked to the point of vomiting.
"If someone like me has no communication issues can be choked when someone is feeding me than what is like for people who can't communicate the way I can."
Implications for the National Disability Insurance Scheme
In September, Prime Minister Scott Morrison announced a Royal Commission into aged care services after an ABC Four Corners investigation documented instances of abuse and neglect of the elderly in nursing homes.
Commissioner Rogers said the report's findings are relevant for the Royal Commission.
"But generally some of these things are generalisable around where a person presenting with risks to their health in any setting -- there needs to be an assessment of that risk and an adequate support and management plan around that. And we need to ensure that staff follow those matters.
"Generally that will apply across settings, but there could be individual differences. The issues for people in aged care are different sometimes than for people without a disability. However, there are people with an intellectual disability -- or another disability -- in aged care. So clearly, some of these issues are comparable for them. And there are lessons [in the report] for all of us."
He said the findings should also inform the national rollout of the National Disability Insurance Scheme -- and the monitoring of service providers.
"I think it is important that we don't just review and state the causes for poor support for people. It is important now that service providers critically examine their processes and their policies. And that they ensure that they have the right assessments and policies in place to keep people safe.
"And that the staff employed are made aware of that with good record keeping so they are constantly alert to the risks of the people with them."