Deceased
Dorothy May Nelson
Demographics
81y, female
Coroner
Coroner Simon McGregor
Date of death
2017-12-20
Finding date
2020-04-22
Cause of death
Complications of choking on a food bolus in a woman with dementia
AI-generated summary
Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despite facility claims of 2cm maximum) and collapsed during lunch. Staff provided back thrusts but failed to recognise cardiorespiratory arrest and did not commence CPR. There was a 5-10 minute delay before recognising the severity, with conflicting staff accounts suggesting they initially thought she had a TIA rather than choking. Ambulance arrived 20 minutes after collapse. Critical clinical lessons: choking can present without typical symptoms (no coughing/wheezing); staff must recognise progression to cardiorespiratory arrest; facility policies must be reviewed by external experts; accurate record-keeping and direct communication with next-of-kin are essential; and food size monitoring requires robust processes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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