Finding into death of Roger David Batchelor
Deceased
Rodger David Batchelor
Demographics
57y, male
Coroner
Coroner Simon McGregor
Date of death
2021-02-28
Finding date
2022-02-18
Cause of death
Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper airway obstruction
AI-generated summary
A 57-year-old man with intellectual disability and a documented history of choking died from hypoxic ischaemic encephalopathy following airway obstruction by food at a day activities program. Despite having a choking management plan in place since 2009 and speech pathology assessments in 2019–2020, critical information was not accessible to staff supervising the meal. The coroner found care was reasonable but identified system failures in information sharing: the choking plan was not reflected in the support plan, recent speech pathology reports were not forwarded to the day program, and food brought from home was not checked by staff before consumption. The coroner commended subsequent system improvements including better document integration, mandatory updates to support plans following health changes, and new risk information sheets for participants.
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
Contributing factors
- Choking management plan not reflected in support plan
- Recent speech pathology assessments not accessible to day program staff
- Food brought from home not checked by staff for suitability before consumption
- Inadequate supervision at mealtime - one staff member in office, participant out of direct line of sight
- Poor information sharing between integrated health service departments
- Support plans reviewed only annually rather than after significant health changes
Coroner's recommendations
- WWHS to ensure support plans are updated every time there is a significant change to participant needs, rather than upon annual review only
- WWHS to proactively seek out updated medical and allied health assessments as part of annual review process
- All WWHS allied health staff to forward reports relating to NDIS participants to program manager for inclusion in participant file and triggering support plan updates
- WWHS to review support plans of all NDIS group activity participants to ensure all medical and allied health recommendations are included
- Transition from physical participant files to electronic client file management system with alerts for health and safety issues
- Development and use of client risk information sheets for day program participants highlighting particular needs and risks
- Melba Support Services to designate specific delegate to report deaths to Victoria Police
- Melba Support Services to list all chemical restraint and PRN medication on residents' mental health care plans
- Melba Support Services to review mental health care plans and complete behaviour support plans where needed by NDIS registered practitioners
Full text
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