Coronial

72 results for aspiration choking

VICmental health2023-05-22

Finding into death of Peter Henry Scerri

60y · Male·Respiratory obstruction (choking by food)

…ry Scerri, a 60-year-old man with long-standing schizophrenia and mild intellectual disability, died from choking on food while eating pizza in a mental health inpatient unit. He had been admitted for management of cloz…

psychiatryemergency medicineclozapine
VIC2025-09-10

Finding into death of Tracie Lyndal Markwick

54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…

Tracie Lyndal Markwick, a 54-year-old woman with intellectual disability and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-mod…

speech pathologyemergency medicineamisulpride
QLDaged care2018-06-05

Milward, Paul Joseph

53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…

…rd, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified minced moist diet w…

geriatric medicinespeech pathologycommunicationsystemsodium valproate
VICcommunity2026-04-01

Finding into death of Jimmy Delcus

56y · Male·Aspiration of food bolus

…y Delcus, a 56-year-old man with autism, intellectual disability and schizoaffective disorder, died from aspiration of a food bolus while eating lunch in a park. He was receiving supported living services through Aruma u…

NSWmental health2019-06-04

Inquest into the death of Andrea Sewell

46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…

…ic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychiatric intensive care unit (PICU). She had a prior history of swallowing …

psychiatryneurologyantipsychotic medications
VICaged care2026-04-28

Finding into death of Saba Pietropaolo

90y · Female·Choking

A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pat…

geriatric medicinespeech pathologysystem
VIChospital2025-09-30

Finding into death of Richard Mark Ellis

64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…

… with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He presented to the ED the same day, was…

emergency medicinepsychiatryamisulpride
VIC2019-08-07

Finding into death of Bartosz Zgadzaj

39y · Male·Hypoxic ischaemic encephalopathy complicating acute upper airway obstruction by …

… of dietician's recommendations to cut food into bite-sized pieces; absence of staff training in managing choking risks; inadequate supervision during meals. Although a Nutrition and Swallowing Issue Checklist was compl…

emergency medicineintensive carediagnosticcommunicationmidazolam
TAS2020-12-17

Coroner's Finding: Kettle, Terrence Michael

69y · Male·asphyxia due to choking on food

…ies (diabetes, amputation, prostate cancer, recent MI) and cognitive impairment, died from asphyxia after choking on food while a resident at Roy Fagan Centre, a psychiatric hospital for older persons. He was being assi…

geriatric medicineemergency medicine
TAShome2023-11-14

Coroner's Finding: de-identified OV

1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…

An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he …

paediatricsemergency medicineadrenaline
TAS2019-01-11

Coroner's Finding: Dunster, Kenneth Francis

52y · Male·asphyxia due to choking on food

…th Dunster, a 52-year-old man with chronic schizophrenia and cognitive decline, died from asphyxia due to choking on food at Millbrook Rise Rehabilitation Centre. He had a documented, well-known choking risk due to his …

psychiatryemergency medicinesystemcommunicationclozapine
VICaged care2022-09-20

Finding into death of Tom Owen Row

59y · Male·Choking asphyxia

…ith intellectual disability, dementia, Fragile X Syndrome, and Chromosome 18 Deletion Syndrome, died from choking asphyxia at a residential care facility. He had a prior choking incident in 2019 with recommendations for…

geriatric medicinepsychiatrysystemrisperidone
TAScommunity2022-07-29

Coroner's Finding: Chamberlain, Pamela Jacqueline

55y · Female·asphyxia due to choking on food (steak)

…luding morbid obesity, schizophrenia, depression, and substance use disorder died from asphyxia caused by choking on food while at a friend's home in supported accommodation. She was on multiple central nervous system d…

emergency medicinepsychiatrysystemcommunicationdiazepam
VIChome2012-08-16

Finding into death of LUCIA DI PIETRO

42y · Female·Global hypoxic-ischaemic brain injury due to upper airway obstruction by food bo…

Lucia Di Pietro, a 42-year-old woman with severe autism and epilepsy living in Department of Human Services disability accommodation, choked on roast beef during supervised dinner on 1 August 2010. Emergency services arr…

emergency medicineintensive care
VIChospital2024-08-07

Finding into death of Georgios Stamkos

68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…

A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised hospital meal. He had been…

psychiatryspeech pathologyrisperidone
SAaged care2008-06-06

Coroner's Finding: MANN Richard Lesley

45y · Male·choking on food

…ity and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and monitoring preceded his death: he received wrong medication…

psychiatrygeneral practicemedicationcommunicationhaloperidol
VICaged care2022-08-01

Finding into death of Phillip Charles Hodges

72y · Male·Choking on a food bolus

A 72-year-old man with vascular dementia, stroke history, and dysphagia died from choking on food while being fed by a nurse in aged care. The coroner found the death was preventable due to staff…

geriatric medicinespeech pathologydiagnosticcommunicationlamotrigine
TAShospital2022-12-15

Coroner's Finding: Mather, Robert Andrew

80y · Male·asphyxia due to choking on food

Robert Mather, 80, died from asphyxia due to choking on food while hospitalised with acute psychosis, severe malnutrition, iron deficiency anaemia and urinary…

psychiatrygeriatric medicineantipsychotic medications
SAaged care2019-06-12

Coroner's Finding: SINCLAIR Colin George

68y · Male·Obstruction of airways by foodstuffs with contributing alcohol-related dementia

…fed excessive food in his mouth during dinner. Staff intervened appropriately by removing his plate, but aspiration occurred. Paramedics found total airway obstruction requiring forced intubation. The coroner found no pr…

geriatric medicinespeech pathology
VICaged care2021-06-23

Finding into death of Kathryn O'Rourke

48y · Female·Hypoxic/Ischaemic Encephalopathy; Aspiration of Food with Respiratory Arrest wit…

…g multiple residents during mealtime with divided attention. A new seating arrangement designed to reduce choking risk had been trialled the previous day but not communicated to staff on duty, so was not implemented. Cl…

intensive careemergency medicinecommunicationsystemclonazepam

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