Coroner's Finding: LESLIE Mona Belle
Deceased
Mona Belle Leslie
Demographics
95y, female
Date of death
2004-09-28
Finding date
2007-08-02
Cause of death
asphyxia due to glottic obstruction by food
AI-generated summary
A 95-year-old female with advanced dementia died from asphyxia caused by food impaction in the glottis. She was prescribed a soft diet (soft vegetables, vitamised meat) but was served and fed a meal containing large uncooked potato pieces, intact peas, diced carrots, and onion rings. Care staff did not verify dietary requirements despite seeing inappropriate food textures. When choking began, the registered nurse incorrectly attributed coughing to chest infection rather than recognised choking, failed to consult the facility's choking protocol, and did not position the patient appropriately for airway clearance. Early recognition of choking, proper positioning on the side, and application of thoracic thrusts might have improved survival chances. Administrative failures included inconsistent care planning, staff unfamiliarity with care plan location, and insufficient verification of dietary appropriateness before feeding.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- food served did not conform to prescribed soft diet
- large unvitamised pieces of potato, peas, carrots, and onion rings served instead of soft diet
- care staff did not verify dietary requirements despite observing inappropriate food texture
- registered nurse failed to recognise choking episode
- registered nurse incorrectly diagnosed chest infection instead of choking
- failure to apply choking protocol despite its availability
- inappropriate positioning of patient during choking episode
- care plan stored in wardrobe, not accessible to bedside care staff
- transcription error in computerised care plan listing vitamised diet instead of soft diet
- no dietary change form issued to implement speech pathologist's recommendation to return to ward diet
Coroner's recommendations
- Canterbury Close Nursing Home should reinforce with staff that when residents are in distress from coughing during a meal, staff must not dismiss the possibility of choking until proper steps have been taken to exclude choking as a diagnosis
Full text
Related cases
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.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —