Inquest into the death of Jordan Leigh SARGENT
Deceased
Jordan Leigh Sargent
Demographics
21y, female
Date of death
2013-03-13
Finding date
2014-04-07
Cause of death
hypoxic brain injury due to choking on food, with Bardet-Biedl Syndrome as a contributing factor
AI-generated summary
Jordan Sargent, a 21-year-old with Bardet-Biedl Syndrome causing intellectual disability and developmental delays, died from hypoxic brain injury after choking on a Jaffa lolly while being driven in a minibus by a disability support worker. Critical clinical lesson: documentation of choking risk was completed at intake but not retained in her active file, and subsequent assessments incorrectly recorded no eating difficulties despite her mother's explicit warnings about rapid eating and choking risk. The support worker had no access to accurate risk information. The coroner found no breach of policies then in force and no unreasonable delay in response, but emphasised the importance of maintaining complete, accurate, and accessible clinical documentation regarding aspiration risks in clients with developmental disabilities. Enhanced risk assessment processes for eating while in transit were recommended.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- absence of critical risk assessment documentation from active file
- inaccurate updating of nutrition and swallowing checklist
- loss or misfiling of initial intake documentation detailing choking risk
- lack of communication to support worker about eating difficulties
- food consumed while in moving vehicle
- delay in stopping vehicle when choking was first reported
Coroner's recommendations
- Implement careful and fully informed risk assessments for clients eating in motor vehicles, rather than blanket prohibition, to avoid discrimination while managing aspiration risks
- Improve documentation procedures to ensure nutrition and swallowing risk assessments remain accurate and accessible in active client files
- Ensure that critical risk information provided by families at intake is retained, properly filed, and reviewed regularly
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