Finding into death of Deva Rebecca Frijlink
Deceased
Deva Frijlink
Demographics
42y, female
Date of death
2018-12-28
Finding date
2022-03-28
Cause of death
Choking on a food bolus
AI-generated summary
Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a shared accommodation facility. Despite having a documented meal support plan requiring supervision, small food pieces, and specific precautions to prevent choking, she aspirated food while being supervised during lunch. The care worker was familiar with Deva's needs and attempted intervention when distress was observed, but resuscitation efforts were unsuccessful. Key clinical lessons include the critical importance of adhering strictly to individualised dysphagia management plans, ensuring staff receive adequate training in choking risk recognition and management, maintaining constant vigilant supervision during meals for high-risk individuals, and ensuring food is consistently prepared according to recommendations. The case highlights risks when vulnerable individuals with swallowing difficulties are in congregate settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Inadequate adherence to individualised meal support plan
- Food pieces may not have been sufficiently small as recommended
- Mealtime supervision during excursion outside normal facility setting
- Potential inadequate staff training in choking risk management
- Medications detected at post-mortem (benzodiazepines, antipsychotics) potentially causing CNS depression and impaired coordination
Coroner's recommendations
- Villa Maria Catholic Homes to ensure strict adherence to individualised meal support plans for all residents with identified choking or aspiration risk
- Improved training for direct care staff in mealtime management, choking recognition, and dysphagia risk management
- Consistent preparation of food according to recommended modified diet specifications
- Enhanced supervision protocols during meals, particularly during excursions outside the normal facility environment
Full text
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