Finding into death of Lorraine Simmons

Contributing factors

• Failure to provide appropriate mealtime assistance despite high aspiration risk
• Inadequate implementation of modified feeding technique (spoon feeding)
• Lack of use of recommended Provale cup for independent drinking
• Inadequate staff training on dysphagia management
• Repeated hospital admissions for aspiration pneumonia prior to final admission
• Underlying dysphagia and intellectual disability
• Unavailability of registered nurse at residential facility

Coroner's recommendations

1. Implementation of quality improvement actions at 50-52 Crispe Street, Reservoir including staff meeting to review Commissioner's findings
2. Training session delivered by speech pathologist on aspiration pneumonia, signs, symptoms, risk factors, and support requirements for people with swallowing difficulties
3. Development of current Mealtime Assistance Plans for all residents at risk of aspiration, reviewed by speech pathologist
4. Development and delivery of e-learning module on safe mealtime management for disability support workers
5. Participation in Commissioner's Mealtime Support Advisory Groups to address gaps in mealtime management resources and guidelines
6. Distribution of safe mealtimes poster to group homes to increase awareness of swallowing and choking risks
7. System-wide training and development programs for disability support workers funded by Victorian Government
8. Ongoing review of resident dysphagia requirements and mealtime plans