Finding into death of Gregory Donald Cole
Deceased
Gregory Donald Cole
Demographics
50y, male
Date of death
2009-06-25
Finding date
2015-05-08
Cause of death
Cerebral hypoxia and bronchopneumonia post episode of choking
AI-generated summary
Gregory Donald Cole, age 50, was a Wyndham Lodge aged care resident with significant disabilities including post-stroke paralysis and dysphagia requiring modified diet. He died on 25 June 2009 from cerebral hypoxia and bronchopneumonia following aspiration of a sausage roll on 23 June 2009. The coroner found his meal was delivered to his room by an unknown staff member, violating established protocols for supervised eating at the nurses' station. Although the meal was covered, the coroner concluded it was more probably than not that the sausage roll was inadvertently supplied by staff. Established supervision protocols were not followed. A speech pathologist had previously documented requirements for finely chopped foods. Contributing cardiac disease was present at autopsy. The coroner found system and communication failures in responsibility allocation between kitchen and nursing staff, and noted that subsequent improvements to food labeling and supervision protocols have been implemented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease
- Failure to implement meal supervision protocols
- Delivery of food to room rather than supervised eating area
- Confusion between kitchen and nursing staff regarding responsibility for food preparation
- Possible failure to properly prepare food according to dietary specifications for dysphagia
Coroner's recommendations
- Clear delineation of responsibilities between kitchen and nursing staff for meal preparation and service
- Consistent protocols for supervising meals for residents with modified dietary requirements
- Nursing staff supervision of residents with dysphagia during meals in designated supervised areas
- Maintenance of awareness and adherence to dietary restrictions documented by speech pathologists
- Implementation of colour-coded labeling and Australian Standards categorization for meal consistency requirements
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