Coronial
VICother

Finding into death of Joanne Callahan

Deceased

Joanne Avis Callahan

Demographics

43y, female

Coroner

Coroner Katherine Lorenz

Date of death

2018-11-01

Finding date

2022-03-10

Cause of death

choking on a food bolus

AI-generated summary

Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her residential care provider (the Department) and the day program (Gateway Health) meant Gateway staff were unaware of her documented choking risk and swallowing difficulties. On the day of death, supervision was inadequate due to staffing gaps during lunch—one staff member left early to another shift, another escorted clients elsewhere, and seating arrangements prevented direct line-of-sight observation of Joanne. Staff responded appropriately once choking was recognized, but earlier detection might have been possible with better supervision. The coroner found the Department failed to communicate choking risk information to Gateway Health, and Gateway's supervision on the day was inadequate, though could not definitively determine if adequate communication or supervision would have prevented death.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

speech pathologyparamedicineemergency medicine

Error types

communicationsystemdelay

Clinical conditions

intellectual disabilityautismepilepsydysphagiachoking riskhypertension

Procedures

intubationcardiopulmonary resuscitation

Contributing factors

  • Department failed to communicate documented choking risk to Gateway Health
  • Inadequate supervision during mealtime
  • Staffing gaps during lunch period
  • Staff member left 20 minutes early to commence afternoon shift elsewhere
  • Another staff member escorting clients across the road
  • Seating arrangements prevented direct line-of-sight visibility of Joanne
  • Standard 1:4 staffing ratio not adjusted for client requiring 1:1 supervision with meals
  • Lunch served earlier than usual
  • Gateway Health staff unaware of Joanne's specific mealtime supervision needs
  • Critical health documents not provided to day program provider

Coroner's recommendations

  1. Gateway Health to implement changes to rostering to maintain staffing ratios throughout shifts and handover periods
  2. Gateway Health to ensure one staff member is never alone with a group of clients
  3. Gateway Health to review and update Disability Day Program Model of Care
  4. Gateway Health to revise policies for group and community inclusion activities
  5. Gateway Health to update client intake information processes to identify choking risk at intake and improve communication to alert staff
  6. Gateway Health to audit all clients' mealtime information to find and fill gaps with documents from other services
  7. Gateway Health to provide training programs about dysphagia and swallowing
  8. Gateway Health to audit all staff for first aid training currency
  9. Gateway Health to invest in new systems and practice of risk assessment
  10. Gateway Health to develop Memorandum of Understanding with Home@Scope regarding information sharing
  11. Department to continue implementing action plan addressing Disability Services Commissioner's Notice to Take Action
  12. Department to ensure critical information documents are shared with disability service providers supporting residents
  13. Continue implementation of Safe Mealtimes poster distribution to group homes
  14. Continue delivery of 'Co-Creating Safe and Enjoyable Meals' training to direct support workers across transfer providers
Full text
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