Inquest into the deaths of Dimosthenis Gesios and Maureen McGreevy

Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete airway occlusion. Ms McGreevy: food bolus obstructing airways.

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 supervision of swallowing; a large food bolus formed and obstructed his airway. Ms McGreevy received an incorrect meal tray containing buttered bread instead of her prescribed minced diet; bread was later found obstructing her airway. Critical failures included: inadequate staff training and understanding of dysphagia management and the IDDSI Framework; inconsistent communication of dietary restrictions; nursing staff deliberately omitting choking from incident reports despite recognising it as a possibility; and absence of clear policies on gelled bread preparation. Both deaths were preventable with proper diet compliance, staff competency assessment, and incident transparency.