C, a child aged 14 - Non-inquest findings

Contributing factors

• Foetal alcohol syndrome with associated swallowing difficulties
• Intellectual impairment and communication limitations
• Food accessed in uncontrolled environment outside eating plan supervision
• Lack of staff recall or formal documentation of eating plan at point of incident
• Inadequate understanding and compliance with individualised eating management plan

Coroner's recommendations

1. Implementation of recommendations from the Public Advocate's report 'Upholding the right to life and health: A review of the deaths in care of people with disability in Queensland'
2. Development of a Framework to Improve Health Care for People with Intellectual or Cognitive Impairment
3. Establishment of local, regional and state-wide health networks led by Health and Hospital Services and QCIDD to provide clinical leadership and support
4. Use of hand-held health records to ensure continuity and foster better communication between health service providers and carers
5. Implementation of minimum standards in NDIS Code of Conduct including health management guidelines, risk management policies, first aid training, and critical incident reporting
6. Increased understanding and training within disability services regarding food preparation, physical positioning, supervision, pacing during meals, and emergency care
7. Designation of a responsible person to coordinate and review health care for people with disability in residential care
8. Staff training on recognising risks related to eating, drinking, swallowing and breathing difficulties
9. Development and strict compliance with individualised mealtime management plans with regular reviews
10. Department of Communities, Child Safety and Disability Services to review resources available to staff for home visiting children in out of home care
11. Strengthened interdisciplinary approaches, collaboration and communication between child safety services, disability services, placement services and schools