Coroner's Finding: DAMIANOU Dimitra

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

1. RAH ensure nursing staff read patient progress notes or clinical records at commencement of shifts, particularly regarding dietary requirements
2. All handover documentation be checked by a person in authority to ensure accuracy against instructions in clinical records
3. RAH reinforce necessity for nursing staff to ensure dysphagic patients receive meals of correct consistency
4. RAH clarify duties and responsibilities of nursing staff in relation to feeding dysphagic patients
5. RAH ensure nursing staff caring for swallowing disorder patients understand individual risk factors to identify inappropriate meal consistency
6. RAH give further consideration to introduction of computerised communication between wards and kitchen, especially for wards caring for dysphagic patients