The mother and two older sisters of Heather McCabe this week sat through an inquest at Wollongong Court House into the 48-year-old's death on April 5 last year.

Deputy State Coroner Geraldine Beattie found that Ms McCabe's death from asphyxiation after choking on food at the Gladstone Street home was "accidental".

However, Ms Beattie recommended to the Minister for Disability that a system be implemented to ensure there was a "comprehensive and documented investigation and review of systems" in light of the incident.

Ms Beattie said Ms McCabe was known to be at high risk of choking, with a "tendency to place large volumes of food in her mouth, leave it there and then run off or move around".

However, despite a policy in place at the Ageing, Disability and Home Care facility that no food be left out, the inquest noted that "food had been left unattended on a plate and in pans in the kitchen" on the evening of her death.

Ms McCabe's mother Daphne McCabe and sisters Maree Ellem and Susan Brown are now calling for reviews to take place at group homes across the nation.

"We know nothing can bring Heather back," Ms Brown said. "However, our family, and especially our mother, has been such an advocate for disability services in the Illawarra.

"We want a review to implement more training for staff so that parents and family members can feel more confident to place their family members with disabilities in care.

"We don't want them to go through what we have in the past 13 months."

Ms Ellem said her sister's behaviour management plan had included an eating plan due to her "complex behaviour support needs and related mental health issues".

"No food was to be left out and she was supposed to be supervised at all times," she said. "There was a duty of care that she was to receive and this failed in her case."

The inquest heard that locks had been put on the refrigerator and pantry at the group home while staff were directed to empty all pots and pans once cooking was complete and not leave any food out.

The plan stated: "Heather on occasions if unsupervised will attempt to access the fridge/pantry and gorge food and drink. This has found to place Heather at risk for chocking [sic]."

On April 5, 2013, Ms McCabe returned to the group home about 5.30pm after an outing with a disability support worker, to find another worker and client eating a meal at the dining table. According to evidence presented at the inquest, another meal was plated up and sitting on the kitchen bench while Ms McCabe's meal was still in a frying pan and saucepan on the stove.

One of the workers told Ms McCabe to go and have a shower, as per her usual routine, and the two workers continued a conversation until they heard a call for help.

That worker had found Ms McCabe in the hallway "appearing to shove food in her mouth with both hands very aggressively. Her hands were moving around her mouth and it looked like she was trying to force in as much as she can".

Despite staff retrieving a "palm-sized" amount of food from Ms McCabe's throat and commencing CPR, and subsequent resuscitation efforts by paramedics, Ms McCabe died.

Ms Ellem said her sister had lived at group homes for 26 years, the last five at the Bellambi home.

"During her time at the group home Heather was treated with dignity, respect and courtesy," she said. "We have no animosity towards the staff - we feel there was a communication breakdown."

Ms Brown said the loss of their "beautiful sister" had left a big hole in their lives.

"I still have nightmares about what my family had to see and endure on the night of her death," she said. "My mother has always been small but stoic. Now she constantly blames herself for what's happened to her youngest child."

Mrs McCabe struggled to find the words to express her grief: "It's tragic, and I felt it could have been avoided."