The man died in May 2020, three days after being fed by workers at a residential home operated by Valmar Support Services in the Canberra suburb of Richardson.
The disability and aged care provider admitted its shortcomings after being pursued by the NDIS Quality and Safeguards Commissioner in the Federal Court.
On Wednesday, Justice Elizabeth Raper "reluctantly" ordered the company pay a fine of more than $1.9 million due to 24 breaches of legislation governing how NDIS providers operate.
Valmar did not provide the level of supports required under the NDIS, a judge said. (Mick Tsikas/AAP PHOTOS)
She noted the penalty was low given the seriousness of the breaches and their fatal results, saying the court was likely to impose a much higher fine next time over similar conduct.
The judge described the resident's death as a terrible event.
"Valmar did not provide the level of supports they were required to provide under the NDIS, leading to very grave and tragic circumstances where one of the residents died," she said in her judgment.
The man was non-verbal, with an intellectual disability, autism, type 2 diabetes and Prader-Willi syndrome, a genetic disorder linked to an excessive appetite.
Dietary and meal-time management plans prepared for the man recommended cutting soft or moist food up into small pieces.
"It's important that I'm supervised when eating, as sometimes I force food into my mouth too fast and a choking hazard is present," his quick-reference guide read.
Valmar and 13 inadequately trained staff placed two other residents in danger of choking by failing to include information provided by dieticians in their eating and drinking plans, Justice Raper said.
The firm had not upheld the fundamental purpose of the NDIS scheme, which was to provide high quality support services, she found.
"Such services cannot be provided if the workers who provide them are given no training," the judge wrote.
"The whole scheme fails."
There was a need to send a clear message to Valmar and other disability support providers about the consequences of a failure to train, audit or supervise compliance with dietary plans, the judge said.
In imposing the penalty - which had been agreed by the NDIS commissioner and Valmar - she noted the firm had no prior breaches of the same type and it had taken steps to improve its training, assessments and compliance.
Lifeline 13 11 14
beyondblue 1300 22 4636
