An NDIS provider has been hit with a record fine following the tragic death of a man in its care due to failures in training and mealtime management. The Federal Court has imposed a $1.9 million penalty on Valmar Support Services, marking the highest-ever fine handed to an Australian NDIS provider.
The case centred on the death of a 47-year-old man who choked on a toasted salami and cheese sandwich in May 2020 while living in a group home managed by Valmar in Canberra.
The man, who was non-verbal and had multiple disabilities, including autism, type 2 diabetes, and Prader-Willi syndrome, had specific dietary requirements to mitigate his risk of choking. Despite this, improperly trained staff failed to follow his meal plan, which specified that his food should be soft, moist, and cut into bite-sized pieces.
NDIS Quality and Safeguards Commissioner Louise Glanville described the incident as a preventable tragedy, emphasising the importance of providers adhering to safety standards.
“NDIS participants put their trust in providers to deliver safe and high-quality supports,” Ms Glanville said. “Failure to meet these obligations is unacceptable and will result in substantial penalties for providers.”
The court found Valmar had long been aware of the man’s risk of choking but failed to take appropriate measures. Despite repeated recommendations from a dietitian to engage a speech pathologist for his swallowing issues, no such action was taken. This negligence ultimately contributed to the man’s untimely death.
On the day of the incident, the sandwich prepared by a staff member was neither soft nor moist, as required by his meal plan. The man choked and collapsed, with paramedics unable to clear the blockage in his airway. He died several days later in hospital.
Justice Elizabeth Raper, who presided over the case, criticised Valmar for its lack of training and oversight. She noted that staff had received no training on safely supporting a person with a disability who was at risk of choking.
“This is not a case where some, but inadequate, training was provided—there was none at all,” Justice Raper said. She added that the failure to provide adequate training undermined the purpose of the NDIS, which aims to empower individuals with disabilities through high-quality, tailored support.
The court heard that Valmar’s lapses extended beyond this one incident, with inadequate supervision of meal plans and safety audits affecting other group home residents.
In the aftermath of the tragedy, Valmar has implemented significant changes to its practices. A registered nurse has been engaged to train hundreds of staff on choking and swallowing risks, and the organisation now mandates swallowing risk assessments for all residents.
Annual reviews by speech pathologists have also become standard, with more frequent assessments for individuals identified as high-risk.
In a statement, Valmar expressed deep regret over the incident, acknowledging the distress caused to the victim’s family and others involved.
“Following this tragedy, we provided the victim’s family with compassion, support, and care,” a spokesperson said. “We have worked closely with the NDIS Quality and Safeguards Commission to ensure the highest standards of safety for those in our care.”
Valmar has since conducted a comprehensive audit of its food management processes and pledged to continue seeking opportunities for improvement.
