Coronial
VICaged care

Finding into death of Nerilee Elizabeth Barfoot

Deceased

Nerilee Elizabeth Barfoot

Demographics

30y, female

Date of death

2013-04-13

Finding date

2017-05-31

Cause of death

Global cerebral ischaemic injury and bronchopneumonia following PEA arrest in a woman with Lennox-Gastaut Syndrome

AI-generated summary

A 30-year-old woman with Lennox-Gastaut Syndrome, a severe treatment-resistant epilepsy, died following cardiac arrest at a disability residential care facility. She was found entangled in a swing seat armrest on 7 April 2013 and died six days later from global cerebral ischaemic injury. The coronial investigation found no evidence that supervision was inadequate at the time of the incident. The coroner could not determine whether she experienced cardiac arrest during a seizure or whether entanglement caused hypoxia leading to arrest. Prior to this death, the swing seat had not been perceived as hazardous. Following the incident, Focus implemented improved risk assessment procedures for garden furniture and enhanced occupational health and safety protocols.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Seizure whilst on swing seat
  • Possible entanglement in swing seat armrest causing airway obstruction
  • Absence of timely observations at critical time period
  • Removal of helmet before incident

Coroner's recommendations

  1. Extension of risk assessment policy to include assessment of risks posed by use of garden furniture including swing seats, with OH&S Team consultation prior to purchase or installation
  2. Introduction of new Asset Register to capture gifts and identify items for OH&S checking
  3. Implementation of new OH&S policies relating to hazard identification and control, purchase of furnishings, manual handling, and workplace inspection procedures
Full text

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