Finding into death of Dorothy May Nelson
Deceased
Dorothy May Nelson
Demographics
81y, female
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.
Error types
Drugs involved
Contributing factors
- Food bolus of approximately 4cm lodged in trachea at carina
- Failure to recognise cardiorespiratory arrest
- Delay in commencing CPR
- Inadequate first aid response to choking
- Confusion about resuscitation status
- Inconsistent and inadequate staff communication
- Dementia as underlying condition affecting swallowing safety
- Delay of 5-10 minutes before recognising gravity of situation
Coroner's recommendations
- Annual drills for staff around responding to a choking incident should be included as part of First Aid Response training at all residential aged care facilities, including Kerala Manor
- All staff at Kerala Manor should receive education in assisting residents with eating at meal times, including how to manage safe delivery of modified texture foods
- Kerala Manor should submit their policy RHL-D26 CHOKING for review and amendment by an AHPRA approved third party provider to give guidance on best practice for the management of a choking event
Full text
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