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Inquest into the death of Bridie Gilligan

Deceased

Bridie Gilligan

Demographics

42y, female

Coroner

Gallagher

Date of death

2021-05-03

Finding date

2026-02-03

Cause of death

Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange Syndrome

AI-generated summary

Bridie Gilligan, aged 42 with Cornelia de Lange Syndrome, profound intellectual disability and dysphagia, died from hypoxic brain injury after choking on a Yumbo burger at her SIL home on 29 April 2021. Her support worker Margaret Lowry purchased the burger as a treat; when Bridie grabbed it before it could be cut into small pieces and shoved it in her mouth, she choked and became unresponsive. While the coroner found Ms Lowry's supervision on that day appropriate and Ms Lowry responded correctly to the emergency, systemic failures were identified: Ms Campbell's speech pathology assessment was incomplete and not followed up; Ms Rees' meal plan was not properly communicated to or understood by support workers; allied health recommendations for 'soft diet' were not clearly defined; and critical collaboration between speech pathology and dietetics did not occur. The NDIS structure created a separation between the SIL provider (Endeavour) and allied health services that contributed to incomplete risk assessment and inadequate staff training on dysphagia management.

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

Specialties

speech pathologydieteticsemergency medicineparamedicineoccupational therapy

Error types

communicationsystemdelay

Clinical conditions

Cornelia de Lange Syndromedysphagiaintellectual disabilityautism spectrum disorderseizure disordergastroesophageal reflux disease

Contributing factors

  • Incomplete dysphagia assessment not followed up
  • Lack of collaboration between speech pathologist and dietician
  • Unclear definition and communication of 'soft diet' to support workers
  • Support workers had limited understanding of clinical dysphagia terminology
  • Meal plan and recommendations not adequately disseminated to all support workers
  • Inadequate training of support workers by allied health professionals
  • NDIS structural separation between SIL provider and allied health services
  • No direct communication pathway between allied health professionals and support workers
  • Support coordinator role not ensuring follow-up of incomplete assessments
  • No informed consent discussion with substitute decision-maker about food choice risks
  • Impulsive behaviour during food preparation not adequately managed through environmental controls

Coroner's recommendations

  1. The NDIA and NDIS Quality and Safeguards Commission should undertake a review of Support Coordination and systems and processes for SIL providers to access information about allied health supports and recommendations, including development of communication guidelines or protocols to ensure timely and coordinated information flow between providers
  2. The NDIA should consider designating funding for complex case management in participants' plans, either through Support Coordinators or SIL providers, to function as a coordinator across disability and health supports ensuring day-to-day support providers are aware of complex health needs
  3. The NDIA or NDIS QSC should provide clear guidance to NDIS providers on managing conflicts between professional health recommendations and participant choice, including how to record decisions and decision-making processes
  4. The NDIA should include appropriate funding in participants' plans to ensure allied health professionals can deliver training to SIL support providers
  5. Endeavour should explore ways to ensure sub-contractors have access to the RiskMan incident portal to improve information access for all support staff
Full text
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