Coroner's Finding: Pasinski, Alexander

59y · Male·asphyxia due to choking on food

Alexander Pasinski, age 59, died from asphyxia due to choking while an involuntary psychiatric patient in Launceston General Hospital's Northside unit. He had major depression and paranoid schizophrenia with complex psychiatric presentation. After a significant breakfast choking incident causing loss of consciousness and Code Blue activation, the clinical review meeting did not implement soft diet precautions or order comprehensive assessment. At lunch, he aspirated a large meat mass causing complete airway obstruction. Although emergency response was timely, MET arrival was delayed five minutes due to distance from the unit, and resuscitation failed. The coroner found the death accidental, resulting from a 'perfect storm' of medications affecting swallowing, fast eating habits, hypoxia-induced jaw clenching, and delayed response. The coroner identified failure to implement dietary precautions after the morning incident as a preventable system failure. Recommended staff training in Magill forceps use and establishment of complex case review panel.