Coroner's Finding: DAMIANOU Dimitra
Deceased
Dimitra Damianou
Demographics
79y, female
Date of death
2003-04-16
Finding date
2005-11-15
Cause of death
cardio-respiratory arrest consequent upon the aspiration of food
AI-generated summary
A 79-year-old woman with post-stroke dysphagia died from aspiration of food while hospitalised. A speech pathologist prescribed a minced diet after an unsuccessful soft diet trial, but the patient received a soft diet meal at the next service. Communication failures occurred across multiple levels: the speech pathologist's telephone instructions to kitchen staff were not accurately implemented, the dietary change was not clearly transferred during nursing shift handover, and nursing staff did not verify the meal consistency before serving or adequately supervise consumption. The patient was left alone with food despite protocols requiring supervision and placement of food on the unaffected side of the mouth. Key preventable failures included: lack of progress note consultation by incoming nursing staff, inaccurate handover documentation, absence of visible bed cards indicating dietary requirements, and failure to verify the meal list. A computerised kitchen-ward communication system was recommended to reduce reliance on verbal orders.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- provision of soft diet meal contrary to speech pathologist's instruction for minced diet
- failure to accurately communicate dietary change from speech pathologist to kitchen staff via telephone
- failure of kitchen staff to implement minced diet instruction
- inaccurate handover documentation not reflecting minced diet instruction
- failure of incoming nursing shift to consult progress notes containing original dietary instruction
- inadequate supervision of dysphagic patient during meal consumption
- patient left alone with food despite dysphagia protocol requirements
- failure to verify meal consistency before serving
- absence of visible bed card indicating modified diet requirements
- imprecise procedures for meal list verification across ward divisions
- communication breakdown at multiple levels in the care chain
Coroner's recommendations
- RAH ensure nursing staff read patient progress notes or clinical records at commencement of shifts, particularly regarding dietary requirements
- All handover documentation be checked by a person in authority to ensure accuracy against instructions in clinical records
- RAH reinforce necessity for nursing staff to ensure dysphagic patients receive meals of correct consistency
- RAH clarify duties and responsibilities of nursing staff in relation to feeding dysphagic patients
- RAH ensure nursing staff caring for swallowing disorder patients understand individual risk factors to identify inappropriate meal consistency
- RAH give further consideration to introduction of computerised communication between wards and kitchen, especially for wards caring for dysphagic patients
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