Coroner's Finding: Dunster, Kenneth Francis
Deceased
Kenneth Francis Dunster
Demographics
52y, male
Date of death
2015-07-01
Finding date
2019-01-11
Cause of death
asphyxia due to choking on food
AI-generated summary
Kenneth Dunster, a 52-year-old man with chronic schizophrenia and cognitive decline, died from asphyxia due to choking on food at Millbrook Rise Rehabilitation Centre. He had a documented, well-known choking risk due to his lifelong habit of eating rapidly without proper chewing, but no formal risk management strategy was in place despite being identified in his care plan. On 1 July 2015, during lunch with only two staff supervising 11 patients, he choked on chicken. Staff responded appropriately to his collapse, but the choking was not immediately recognised. The coroner found supervision levels were inadequate and that increased staffing during meals may have prevented the death. No individual staff member was criticised. Changes have since been implemented including enhanced staffing during meals and improved first-aid training.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- chronic schizophrenia with cognitive decline
- lifelong habit of rapid food consumption without adequate chewing
- inadequate supervision during mealtime
- no formal choking risk management protocol in place
- staff absence during meal service
- advanced atherosclerotic cardiovascular disease
- antipsychotic medication potentially affecting swallowing mechanism
Coroner's recommendations
- Ensure adequate staffing levels during mealtimes to provide appropriate supervision of patients at risk of choking
- Implement formal choking risk management protocols for identified high-risk patients
- Provide clear training to staff on recognition of choking versus other medical emergencies
- Implement regular dental care programs to reduce choking risk through improved dentition and chewing ability
- Hold regular multidisciplinary meetings between catering, nursing, and medical staff to ensure safe food preparation and appropriate portion sizes
- Display choking first-aid guidance charts in all clinical units
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