Finding into death of Stuart Anthony Wills
Deceased
Stuart Anthony Wills
Demographics
45y, male
Date of death
2014-05-20
Finding date
2021-10-01
Cause of death
Aspiration of food bolus, with cerebral palsy as contributing factor
AI-generated summary
Stuart Wills, a 45-year-old man with cerebral palsy and severe dysphagia, died from aspiration of a food bolus while receiving meal assistance at a supported accommodation facility. Prior to his death, a speech pathologist updated his feeding profile to require all food be pureed and minced. On 20 May 2014, a disability support worker provided him with incompletely processed sausage, which he aspirated. The coroner found this was an isolated lapse in judgment by the support worker rather than failure of training or competence, and did not identify opportunities for prevention. The incident highlights the critical importance of strict adherence to individualised feeding regimes for people with severe swallowing difficulties, especially after recommendations have been updated.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Non-adherence to updated feeding profile requiring pureed and minced food
- Provision of incompletely processed sausage
- Progressive deterioration in swallowing ability and aspiration risk
- Fatigue affecting swallowing ability
Coroner's recommendations
- Increased training in mealtime assistance and dysphagia awareness for disability support workers (implemented by Yooralla from 2015)
- Incorporation of strengthened training in staff induction programs (implemented by Yooralla from July 2018)
- Introduction of checklists for assessment of swallowing ability to prompt identification of changes such as increased coughing
- Encouragement of staff to seek further assessment when changes in swallowing ability are identified
- Continued work with Speech Pathology Australia to support funding for further assessment and therapy supports for residents with swallowing difficulties
Full text
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