An intellectually impaired resident gorged on a jar of hazelnut chocolate spread and choked to death at an Illawarra group home - just 18 months after a similar death at another home.
The mother of the 45-year-old man - who did not want herself or her son named - has urged the NSW Department of Family and Community Services (FACS) to take some action so her son's death was "not in vain".
Lake Illawarra police are investigating the October 2 incident at the Ageing, Disability and Home Care (ADHC) facility in Albion Park Rail and are preparing a report for the coroner before a possible inquest.
The grieving mother said strict protocols were supposed to have been in place due to her son's tendency to gorge on food - including constant supervision at mealtimes and pantry cupboards and fridges to be locked at all times.
However on the morning of October 2, she claimed that her son had managed to get hold of a jar of chocolate spread.
The tragic death comes after the choking death of intellectually disabled woman Heather McCabe at another ADHC group home in Bellambi on April 5 last year.
At an inquest in May, Deputy State Coroner Geraldine Beattie found the 48-year-old's death from asphyxiation after choking on food 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.
A FACS spokesperson told the Mercury the department was "unable to comment on individual client matters to ensure privacy and confidentiality".
"Since a recent coronial inquiry, FACS has strengthened the implementation of existing comprehensive policies and procedures to support the nutrition and swallowing needs of clients including detailed staff training programs," the spokesperson said.
The distraught mother said she had rung the Albion Park Rail group home just half an hour before her son's death and had been reassured that he was fine. Thirty minutes later, she received another phone call telling her of his death.
"My son was autistic and intellectually impaired and used to eat far too quickly and swallow food far too fast," she said.
"Around five years ago, during a shift change, he got hold of a jar of peanut butter and choked on it and started turning blue, and then fell and broke his foot as a result.
"He recovered but the staff were well aware of his condition - there were meant to be strict protocols in place while he was eating."
The man's mother claimed she had discovered that her son had been left alone for a short time on the morning of October 2. He had found a jar of hazelnut chocolate spread, gorged on it and choked to death.
"There's a history of things being swept under the carpet concerning my son," she said.
"The team leader at the home is excellent, and there's some very good carers in the system, but there needs to be some action taken so that [my son's] death is not in vain.
"People who suffer from any sort of intellectual disability have a very small voice - they cannot scream or argue for their rights themselves - so this needs to be properly looked into."
After the inquest into Ms McCabe's death, her mother and two sisters called for reviews at group homes across the region to prevent a similar tragedy.