Finding into death of Bartosz Zgadzaj
Deceased
Bartosz Zgadzaj
Demographics
39y, male
Date of death
2017-11-28
Finding date
2019-08-07
Cause of death
Hypoxic ischaemic encephalopathy complicating acute upper airway obstruction by food bolus
AI-generated summary
Bartosz Zgadzaj, a 39-year-old man with cerebral palsy and intellectual disability, died from hypoxic ischaemic encephalopathy secondary to acute airway obstruction from a food bolus. He choked while eating unsupervised at a group home on 24 November 2017. Multiple preventable failures occurred: no swallowing assessment by speech pathologist; staff unaware of dietician's recommendations to cut food into bite-sized pieces; absence of staff training in managing choking risks; inadequate supervision during meals. Although a Nutrition and Swallowing Issue Checklist was completed, it was not properly communicated to or utilised by staff. The coroner found the death clearly preventable. Key lessons include: timely formal swallowing assessments for residents with communication difficulties; proper staff documentation and awareness of dietary recommendations; mandatory training in choking management; supervision protocols during meals; and effective family communication about specific health risks.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Inadequate supervision during mealtimes
- No speech pathologist swallowing assessment despite entering care with known disability
- Staff unaware of dietician recommendations to cut food into bite-sized pieces
- Absence of staff training in choking risk management
- Poor communication and documentation of dietary requirements to care staff
- Nutrition and Swallowing Issue Checklist completed but not properly utilised
Coroner's recommendations
- Implementation of Nutrition and Swallowing Issue Checklists (NASICs) at entry and exit of residents with swallowing or choking risks
- Formal handover procedures for resident healthcare needs through Entry, Exit, Relocation and Residential Statement (EERRS) documentation
- Completion of NASIC within seven days of resident entering residential service
- Mandatory swallowing and choking assessments for all new residents in DHHS supported facilities
- All swallowing risks referred to Speech Pathologist for assessment
- Dysphasia training provided to all care staff on choking risk management
- Staff induction to include health alerts for all residents
- State-wide audits of NASICs cross-referenced with mealtime assistance plans to ensure consistency
- Improved communication with families regarding specific health risks and dietary requirements
- Documentation and dissemination of dietary recommendations to all staff members
Full text
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