Deceased
Daniel Tyson Pelka
Demographics
19y, male
Date of death
2012-06-25
Finding date
2013-10-02
Cause of death
aspiration of latex glove; intellectual disability
AI-generated summary
Daniel Pelka, a 19-year-old with severe intellectual and physical disability, died from aspiration of a latex glove whilst attending a disability day care centre. He had known propensity to place objects in his mouth and required high-level support (level 5). Despite staff awareness of this risk, insufficient supervision was provided and choking hazards (latex gloves) were inadequately secured. Gloves were stored in accessible locations and used bins were not secure. Staff were changing multiple clients simultaneously with inadequate ratios when Daniel accessed and aspirated a glove from the floor. The facility had recognised staffing shortages pre-incident but these were not addressed. Post-death, comprehensive safety improvements were implemented including secured glove storage, increased staff ratios, improved bin security, and mandatory first aid training.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
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