Deceased
Andrew Phillip John Kursinskis
Demographics
57y, male
Coroner
Coroner Audrey Jamieson
Date of death
2021-10-26
Finding date
2025-11-10
Cause of death
Complications following food aspiration in a man with multiple co-morbidities
AI-generated summary
Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodation. He had a documented mealtime management plan (MMP) requiring soft, bite-sized foods (≤15mm pieces). The chicken schnitzel was prepared as a fine-crumbed, tender, bite-sized meal. An independent speech pathologist considered it a borderline but acceptable meal choice given his history of managing similar foods without incident. The coroner found no causal link between lack of staff training on the MMP and the death. Key clinical lessons include: ensuring clear documentation and supervision of MMP compliance in disability settings; regular review of swallowing management plans; formal staff training and checking systems for mealtime safety; and balancing dietary restrictions with quality of life and food agency. The organisation subsequently implemented comprehensive mealtime management improvements.
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
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…
62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…
John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…
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