Coronial
TAShome2018-10-02

Coroner's Finding: Davis, Alby Fox

3y · Unknown·hypoxic brain injury as a result of asphyxia from choking on a rubber ball

… ball at home. The ball was purchased online for his upcoming birthday party and arrived with appropriate choking hazard warnings for children under 3 years. Despite his mother's immediate intervention including CPR and…

paediatricsemergency medicine
VICaged care2025-07-24

Finding into death of Silvie Marion Burton

89y · Female·Acute upper airway obstruction by food bolus

…e was suboptimal in her final moments. Key clinical lessons include the need for proper staff training in choking management, timely emergency service activation, adherence to evidence-based first aid protocols, and vig…

geriatric medicineemergency medicineproceduraldelaycitalopram
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
TASmental health2016-08-16

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 de…

psychiatryintensive caresystemcommunicationamitriptyline
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
VIC2016-04-14

Finding into death of Miriam Ralph

49y · Female·Unascertained (natural)

…ty, bipolar disorder, Parkinson's disease, and asthma, died at a disability services facility following a choking episode and acute respiratory distress. She had recently been hospitalized for serious injuries from a mo…

emergency medicineforensic medicinebenztrop
VICaged care2010-05-19

Finding into death of Beatrice Ivy Brown

80y · Female·Acute upper airway obstruction secondary to aspiration of food bolus

…d at an aged care facility from acute upper airway obstruction and aspiration of a food bolus following a choking episode. Clinical lessons include: (1) documentation of prior choking episodes should trigger dietary mod…

geriatric medicineemergency medicinecommunicationsystem
VIChospital2024-12-09

Finding into death of Robert Easter

63y · Male·Aspiration pneumonitis with contributing conditions of ischaemic gut, dysphagia …

…, blindness and hearing impairment, died of aspiration pneumonitis following admission to hospital with a choking episode, vomiting, lethargy and abdominal distension. Imaging revealed portal venous gas suggestive of bo…

palliative caregeneral medicine
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
WAmental health2018-09-19

Inquest into the Death of Wlodzimierz DUDEK

69y · Male·bronchopneumonia and hypoxic brain injury following aspiration of food (choking)

…a and hypoxic brain injury. The coroner found the death was accidental and supervision was reasonable, as choking was not identified as a risk despite a previous episode of dysphagia documented four months earlier that …

psychiatryemergency medicinecommunicationsystem
QLDcommunity2016-09-10

C, a child aged 14 - Non-inquest findings

14y · Female·Hypoxic-ischaemic encephalopathy due to choking on food, as a consequence of foe…

…lcohol syndrome, autism, and intellectual impairment died from hypoxic-ischaemic encephalopathy following choking on food during a community outing. She had been in state care since infancy and was largely tube-fed but …

paediatricsemergency medicinesystemcommunication
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
SAhospital2016-02-08

Coroner's Finding: FIDGE Patricia Ann

67y · Female·choking and ischaemic heart disease

Patricia Ann Fidge, 67, died at The Queen Elizabeth Hospital from choking and ischaemic heart disease. She was admitted with delirium, hypernatremia, and multiple comorbidities in…

emergency medicinepsychiatryrisperidone
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
WAmental health2015-11-18

Inquest into the Death of Anna Maria CAMERON

65y · Female·Early bronchopneumonia and hypoxic brain injury following aspiration of food (ch…

Anna Maria Cameron, a 65-year-old woman with treatment-resistant schizophrenia, died from aspiration choking while eating on a psychiatric ward. She had been recently transferred to a rehabilitation unit for reasse…

psychiatryintensive carelorazepam
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
NSWhospital2021-12-23

Inquest into the death of Shelley YOUNG

65y · Female·choking on a tangerine

…ltiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine while an inpatient at Manly Hospital. She had documented choking risk and clear recommenda…

psychiatrygeriatric medicinecommunicationsystemclozapine
VICcommunity2022-02-18

Finding into death of Roger David Batchelor

57y · Male·Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper ai…

A 57-year-old man with intellectual disability and a documented history of choking died from hypoxic ischaemic encephalopathy following airway obstruction by food at a day activities progr…

general practicespeech pathologycommunicationsystempantoprazole
SAaged care2023-12-22

Coroner's Finding: LENS, Christopher

64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …

…died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut butter sandwich. A speech pathologist had recommended supervised oral intake and 20-minute po…

geriatric medicinespeech pathologysystemcommunication
SAaged care2017-05-30

Coroner's Finding: SMITH Arthur

80y · Male·aspiration pneumonia complicating inanition of dementia

…anship in August 2013 due to lack of insight into his care needs. While at the facility he had documented choking episodes requiring soft diet and careful monitoring, low mood, reduced mobility, and signs of respiratory…

geriatric medicinepsychiatry

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