Deceased
Tom Owen Row
Demographics
59y, male
Date of death
2022-02-18
Finding date
2022-09-20
Cause of death
Choking asphyxia
AI-generated summary
Tom Owen Row, a 59-year-old man with intellectual disability, dementia, Fragile X Syndrome, and Chromosome 18 Deletion Syndrome, died from choking asphyxia at a residential care facility. He had a prior choking incident in 2019 with recommendations for pre-cut meals, strokes, and eating speed monitoring. On 18 February 2022, he was found unresponsive with food lodged in his larynx. The coroner found all care plans and policies had been followed on the day of death. Key clinical lessons include: maintaining current Comprehensive Health Assessment Programs and Specialised Health Management Plans in residential care facilities, implementing robust systems for medical reviews when residents cannot attend appointments, and continued vigilance for swallowing difficulties in residents with dementia and developmental disorders, particularly those with prior choking incidents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
90y · Female·Choking
A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —