Deceased
Mark Capovilla
Demographics
39y, male
Coroner
Deputy State Coroner Caitlin English
Date of death
2018-01-18
Finding date
2021-02-24
Cause of death
Choking on a food bolus
AI-generated summary
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at either his residential unit or day service. Critical communication failures occurred: his choking risk was not effectively communicated from his residential provider (DHHS) to Aurora Support Services. While staff at his residence implemented appropriate precautions (small pieces, close supervision, drinks with meals), Aurora classified him as an independent eater requiring no one-to-one supervision. The coroner found the death preventable due to inadequate communication and absence of formal mealtime support plans. Both organisations have since implemented improvements including better inter-agency communication, swallowing checklists, and staff training on choking management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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