Milward, Paul Joseph

Contributing factors

• Non-compliance with care plan requiring supervised moist minced diet
• Extended unsupervised period (two hours) in closed room after providing bread sandwich
• Patient left lying in bed rather than upright position as required
• Residents not served one course at a time as per care plan
• Staff difficulty managing challenging behaviours and patient's insistence on door closure
• Food items provided not strictly in accordance with assessed dietary requirements
• Inadequate supervision despite documented swallowing/choking risk
• Patient consumed food while lying down

Coroner's recommendations

1. That choking deaths of persons in care with a disability be specifically acknowledged as a systemic issue, and strategies to manage, monitor, review and report on this particular issue should be built into the NDIS quality assurance and reporting framework
2. That all staff involved in the provision of care to residential aged and disability care residents be informed of any material change to a resident's care plan prior to the commencement of their next shift (by oral handover or other information sharing means as determined by each organisation)
3. That residential aged and disability care residents' care plans be subject to routine review at least three-monthly and sooner if health or other personal circumstances have changed
4. That residential aged and disability care residents with conditions that affect their ability to swallow should undergo regular medical examinations at intervals recommended by a medical practitioner to assess respiratory health and identify and treat aspiration pneumonia