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Davis, John

Deceased

John Davis

Demographics

50y, male

Coroner

Lock

Date of death

2018-04-10

Finding date

2019-04-17

Cause of death

Hypoxic-ischaemic encephalopathy secondary to choking on food bolus

AI-generated summary

A 50-year-old man with acquired brain injury and intellectual disability died from hypoxic-ischaemic encephalopathy following aspiration of a food bolus during lunch at his disability care residence. The carer appropriately called 000 and commenced CPR, but communication difficulties with the emergency dispatcher delayed recognition of cardiac arrest. Paramedics initially failed to visualise and remove the airway obstruction due to inexperience with laryngoscopy and faulty equipment; a critical care paramedic removed the bolus 10 minutes later. By then, prolonged hypoxia had caused irreversible brain damage. Clinical lessons include: disability care providers should systematically assess swallowing risks using standardised checklists; carers need training to recognise choking and perform basic airway manoeuvres; emergency dispatchers must maintain high suspicion for cardiac arrest despite unclear caller information; paramedics require regular training in foreign body airway removal; and post-hospitalisation recommendations regarding diet and swallowing must be clearly communicated to all care providers.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineparamedicinespeech pathologygeneral practiceintensive care

Error types

diagnosticcommunicationsystemdelay

Drugs involved

midazolammorphine

Clinical conditions

acquired brain injury from birthintellectual disabilityepilepsyobstructive sleep apnoeaaspiration pneumoniapharyngeal dysphagiagastro-oesophageal reflux diseaseosteoporosiscardiac arrestpulseless electrical activitychoking on food bolushypoxic-ischaemic encephalopathy

Procedures

laryngoscopycardiopulmonary resuscitationlaryngeal mask airway insertionintubationbarium swallowCT chest scan

Contributing factors

Unrecognised swallowing difficulties despite previous speech pathology assessments
Lack of communication of post-hospitalisation dietary recommendations from GP to care provider
No systematic swallowing risk assessment tool in place at disability care facility
Delay in recognition of cardiac arrest due to unclear communication with emergency dispatcher
Inexperience of paramedics with laryngoscopy for foreign body removal
Equipment failure: faulty laryngoscope batteries
Lack of documented pre-shift equipment checks
Delay in attendance of critical care paramedic with successful airway clearance
Prolonged hypoxia before paramedics arrived

Coroner's recommendations

National Disability Services should note the findings and pass on to its members a recommendation that they consider implementing a Nutrition and Swallowing Checklist similar to that in use by Multicap (adapted from the NSW Department of Ageing, Disability and Home Care) for use by care providers providing disability care services to those in risk categories for swallowing difficulties.

Full text

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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