Finding into death of Grant White

Contributing factors

• Failure of disability accommodation staff to escalate care despite documented symptoms (fluid retention and laboured breathing) on 9 September 2017
• Staff reliance on resident's verbal assurance of being 'OK' rather than following Specific Health Management Plan protocols
• Failure to contact GP or nurse-on-call despite clear warning symptoms documented in health management plans
• Staff lack of recognition of deterioration in physical health
• Severe underlying cardiac disease including cardiomegaly, mitral regurgitation, atrial fibrillation, and heart failure

Coroner's recommendations

1. The coroner comments on need to amend Coroners Act 2008 (Vic) to ensure vulnerable persons in community service organisation-managed disability accommodation remain captured in coronial jurisdiction following NDIS transition, noting that deaths would no longer be mandatorily reportable if occurring in non-DHHS managed facilities
2. Implementation and enforcement of training for DAS staff to recognise deterioration in residents' physical health and follow treating medical professionals' recommendations
3. Strengthened management of residents' medical needs including documentation and monitoring protocols in disability accommodation services
4. Community service organisations assuming management of DAS homes must maintain policies and practices equivalent to those in Residential Services Practice Manuals, particularly regarding Specific Health Management Plans and medical issue escalation