Inquest into the death of Andrea Sewell
Deceased
Andrea Sewell
Demographics
46y, female
Date of death
2015-09-17
Finding date
2019-06-04
Cause of death
hypoxic ischaemic brain injury as a result of cardiac arrest following a choking episode
AI-generated summary
Andrea Sewell, a 46-year-old woman with Osmotic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychiatric intensive care unit (PICU). She had a prior history of swallowing difficulties from ODS but had made substantial symptomatic recovery by the time of her acute psychiatric admission. The coroner examined whether her swallowing ability was adequately assessed before prescribing antipsychotic medications that could impair swallowing. Expert evidence concluded that without observed eating or drinking difficulties during admission, failure to obtain a speech pathology assessment was not unreasonable, and that her choking was likely due to impulsive eating behaviour rather than ODS-related swallowing dysfunction. No clinical negligence was found. The hospital subsequently implemented improved emergency response procedures including a 24-hour rapid response team.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Procedures
Contributing factors
- history of Osmotic Demyelination Syndrome with prior swallowing difficulties
- antipsychotic medication side effects on swallowing
- impulsive eating behaviour during acute psychiatric illness
- lack of documented swallowing assessment at admission despite neurological history
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