Finding into death of Catherine Ann Collier
Deceased
Catherine Ann Collier
Demographics
51y, female
Date of death
2018-07-26
Finding date
2022-07-06
Cause of death
Aspiration in the setting of end stage down syndrome
AI-generated summary
Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner investigation identified critical gaps in her care: no current individualised mealtime assistance plan despite her progressive dysphagia and increasing seizures; infrequent speech pathology reviews despite neurologist documentation of worsening swallow function in June 2018; and undated communication support information with no formal communication assessment. These deficiencies meant staff lacked current, specific guidance for managing her complex feeding and communication needs. A Notice to Take Action was issued requiring development of individualised mealtime plans, regular speech pathology reviews for residents with dysphagia showing health changes, and communication assessments for non-verbal residents. The coroner did not make formal recommendations but noted the investigation and remedial actions would help prevent similar deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Progressive dysphagia due to advancing hydrocephalus and cognitive decline
- Lack of current, individualised mealtime assistance plan
- Infrequent speech pathology reviews despite documented deterioration
- Outdated communication support documentation
- No formal communication assessment despite complex non-verbal communication needs
- Increasing seizure frequency contributing to swallowing difficulties
Coroner's recommendations
- DFFH to work with service provider Home@Scope to share findings and recommendations from the investigation with staff at 33 Talbot Street, Colac
- DFFH to ensure residents with dysphagia demonstrating changes in health and/or mealtime supports are reviewed by a speech pathologist with current mealtime assistance plans in place
- DFFH to ensure non-verbal residents have speech pathologist communication assessments and current communication support plans, with updates if residents experience cognitive decline
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