Finding into death of Catherine Ann Collier

51y · Female·Aspiration in the setting of end stage down syndrome

Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner investigation identified critical gaps in her care: no current individualised mealtime assistance plan despite her progressive dysphagia and increasing seizures; infrequent speech pathology reviews despite neurologist documentation of worsening swallow function in June 2018; and undated communication support information with no formal communication assessment. These deficiencies meant staff lacked current, specific guidance for managing her complex feeding and communication needs. A Notice to Take Action was issued requiring development of individualised mealtime plans, regular speech pathology reviews for residents with dysphagia showing health changes, and communication assessments for non-verbal residents. The coroner did not make formal recommendations but noted the investigation and remedial actions would help prevent similar deaths.