Deceased
Catherine Ann Collier
Demographics
51y, female
Coroner
Coroner Simon McGregor
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. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…
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