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Case Study 1: Support through quick, remedial response

Choking is one of the leading causes of preventable death in people with disability, so it is important to ensure the risk of choking is managed properly and quickly. Through our reportable incident function, we identified that an NDIS participant was experiencing choking problems frequently. Our priority was to ensure immediate action was taken to address the choking risks of the participant.

We worked closely with the provider to review their practices and risk management approach. We also supported the provider to engage with the participant’s multidisciplinary health team to review their health care and allied health supports; and to put in place a number of new practices – including training for staff - to reduce the risk of choking.

As a result, the participant’s choking episodes reduced, and staff were better equipped to deal with episodes when they arose. The provider also employed a specialist to review its practices with all participants who had choking risks, to improve the safety and quality of their service to all participants.

In this case our actions were swift and corrective in nature. The provider was willing to make the changes and did so with our instruction. The participant was engaged and their networks were involved in the plan in order to improve their supports.

In addition, the Commission undertook initiatives aimed at improving the detection and management of the swallowing problems that can cause choking. These included a grant to develop a training course for people with disability, direct support workers, family members and NDIS service providers on swallowing disorders and mealtime management.

The Commission also developed Provider Practice Alerts, which provide brief, easy to read guidance for Disability Provider services on the recognition and management of swallowing problems.