VICaged care

Finding into death of Silvie Marion Burton

Deceased

Silvie Marion Burton

Demographics

89y, female

Coroner

Coroner Simon McGregor

Date of death

2024-08-25

Finding date

2025-07-24

Cause of death

Acute upper airway obstruction by food bolus

AI-generated summary

An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actual events. There was a 50-second delay before attempting to relieve the obstruction, and a further delay (approximately 4 minutes) before emergency services were contacted. First aid response did not align with St John Ambulance Victoria guidelines, which recommend immediate emergency contact before or concurrent with back blows and chest thrusts. The coroner found care was suboptimal in her final moments. Key clinical lessons include the need for proper staff training in choking management, timely emergency service activation, adherence to evidence-based first aid protocols, and vigilant mealtime supervision for vulnerable residents with cognitive impairment.

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

Specialties

geriatric medicineemergency medicine

Error types

proceduraldelaycommunication

Drugs involved

citalopram

Clinical conditions

acute upper airway obstructionfood bolus aspirationmajor neurocognitive disorderdementiadysphagia risk

Contributing factors

Delay in contacting emergency services (approximately 4 minutes after onset of choking)
Initial delay of approximately 50 seconds before attempting to relieve obstruction
Inconsistent application of recognised first aid techniques for choking
Suboptimal response to choking incident by staff
Resident positioned in semi-reclined position during feeding
Major neurocognitive disorder (dementia) with impaired ability to protect airway

Coroner's recommendations

Regis Mornington (Regis Aged Care) ensure that all staff receive training and guidance to identify and appropriately respond to residents experiencing severe difficulty breathing due to mild or severe obstruction of the airway due to foreign body like food bolus, including updating and/or developing appropriate choking hazard policies and procedures
Regis Mornington (Regis Aged Care) ensure that all relevant staff that require first aid training certification have up to date refresher training including responding to a choking adult or child

Full text

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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.

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