Coronial

59 results for swallowing difficulty

VIChospital2010-05-20

Finding into death of Laurel Faith Howard

52y · Female·Aspiration pneumonia secondary to Alzheimer's disease

…umstances and found no causal link to her care status. Key lessons include the importance of recognizing swallowing difficulties in patients with progressive neurodegenerative disease, appropriate escalation of care leve…

geriatric medicinepalliative caremorphine
VIChospital2021-11-25

Finding into death of Raylene Barbara Armstrong

55y · Female·Aspiration pneumonia in a woman with cerebral palsy (spastic quadriparesis)

…ex medical history requiring pureed foods and thickened fluids. Following GP assessment for coughing and swallowing difficulties on 2 January 2019, she was admitted twice to hospital in January. She was discharged on 18 …

general practicespeech pathologypregabalin
VIChome2025-09-02

Finding into death of Noel John Biggs

66y · Male·Undetermined (natural causes)

…ons including Parkinson's disease, spastic gait syndrome, cognitive impairment, atrial fibrillation, and swallowing difficulties died at his supported disability accommodation home on 20 June 2024. He experienced acute r…

general practiceforensic medicinelevetiracetam
SAaged care2019-05-29

Coroner's Finding: FIELD Glenda Rae

59y · Female·Hypoxic-ischaemic encephalopathy due to acute upper airway obstruction

…dianship order due to chronic paranoid schizophrenia and factitious disorder. Despite eating quickly, no swallowing difficulties were identified and she was on a normal diet. When she collapsed while eating toast, staff …

emergency medicineintensive carefluoxenol
SAhospital2017-04-19

Coroner's Finding: ADAMSON Jean Anne

78y · Female·aspiration on a background of psychogenic dysphagia, intellectual impairment and…

…ound of psychogenic dysphagia, intellectual impairment, and chronic schizophrenia. She had experienced a swallowing phobia that recurred in September 2014, leading to dehydration and acute kidney injury. She was admitted…

general medicinepsychiatrymorphine
VIChospital2022-10-06

Finding into death of Tracey Lee Cooke

55y · Female·aspiration pneumonia

…linical challenge of managing recurrent aspiration in patients with progressive neurological disease and swallowing difficulties. Better recognition of deteriorating health and comprehensive health care planning for resi…

respiratory medicinepalliative caresystemcommunication
VIChospital2012-06-25

Finding into death of Angela Murray

52y · Female·Aspiration pneumonia in a female who had undergone a laparoscopic cholecystectom…

…n her death and her status as a person in care. The case highlights risks of aspiration in patients with swallowing difficulties and neurological conditions, and the importance of recognising haematemesis as a significan…

surgerygeneral practice
QLDaged care2018-06-05

Milward, Paul Joseph

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

Paul Joseph Milward, 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 p…

geriatric medicinespeech pathologycommunicationsystemsodium valproate
VICaged care2022-08-01

Finding into death of Phillip Charles Hodges

72y · Male·Choking on a food bolus

…nd the death was preventable due to staff lack of training in safe feeding techniques for residents with swallowing difficulties, absence of regular speech pathology assessments, and inadequate emergency response skills.…

geriatric medicinespeech pathologydiagnosticcommunicationlamotrigine
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…

…essons include: the critical importance of staff understanding and compliance with individualised eating/swallowing plans for people with intellectual disability; the need for designated health coordinators in residentia…

paediatricsemergency medicinesystemcommunication
TASmental health2016-08-16

Coroner's Finding: Pasinski, Alexander

59y · Male·asphyxia due to choking on food

…ailed. 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…

psychiatryintensive caresystemcommunicationamitriptyline
WAhospital2004-11-12

Inquest into the Death of Mortensen

60y · Female·Aspiration of food in a woman with cerebral atrophy

Jytte Mortensen, a 60-year-old woman with multi-infarct dementia and schizoaffective disorder, died at Graylands Hospital from aspiration of food. She had documented dysphagia requiring a pureed diet and one-to-one super…

psychiatryspeech pathologycommunicationsystem
VICcommunity2025-07-17

Finding into death of John Michael Jurdeczka

62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…

… managing food-related behaviours in vulnerable individuals with dysphagia during community outings, the difficulty of enforcing supervision protocols in non-controlled environments, and the importance of rapid emergency…

speech pathologygeneral practicecommunicationsystemmorphine
SAaged care2016-09-05

Coroner's Finding: BANNISTER Alfred Geoffrey

84y · Male·general inanition on a background of dementia with contributing ischaemic and hy…

Alfred Geoffrey Bannister, aged 84, died at Monreith Aged Care Facility from general inanition on a background of dementia with contributing ischaemic and hypertensive heart disease. He had progressive cognitive decline …

geriatric medicinepsychiatry
VIChospital2013-08-23

Finding into death of Joseph Micallef

55y · Male·Aspiration pneumonia

Joseph Micallef, a 55-year-old man with cerebral palsy and epilepsy living in high care accommodation, died from aspiration pneumonia. He had longstanding dysphagia related to his cerebral palsy, which had caused multipl…

infectious diseasesrespiratory medicinecitalopram
VIChospital2024-11-27

Finding into death of Darryle Rodney Gilbert

65y · Male·Aspiration pneumonia with antecedent cause of secondary progressive multiple scl…

Darryle Rodney Gilbert, a 65-year-old man with secondary progressive multiple sclerosis, died from aspiration pneumonia on 30 December 2022 at Austin Hospital. He had been admitted on 19 December 2022 with aspirated pneu…

respiratory medicineinfectious diseases
VIChospital2025-11-10

Finding into death of Panayotis (Peter) Pavlis

83y · Male·Pneumonia

…f noted signs of acute deterioration (pallor, poor capillary refill, tachypnoea, altered responsiveness, difficulty swallowing) and appropriately arranged hospital transfer. He was admitted for assessment and palliative …

emergency medicinepalliative care
VIChospital2018-11-04

Finding into death of Kathleen Mary Thomas

81y · Female·Aspiration pneumonia

An 81-year-old woman with intellectual disability, cerebral palsy and dysphagia died from aspiration pneumonia. She resided in DHHS care with appropriate preventative measures in place including softened diet and thicken…

general practicepathologyesomeprazole
WAhospital2022-01-05

Inquest into the Death of Terrence Alexander Penman WELLS

61y · Male·metastatic oesophageal neuroendocrine carcinoma

…ophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attributed to missing teeth. The coroner found the medical care provided…

oncologypalliative caremedicationsystempantoprazole
VIChospital2023-11-20

Finding into death of David Drowley

63y · Male·Metastatic lung cancer

… developing the disease whilst incarcerated. He presented to prison medical services in August 2021 with difficulty swallowing and a neck lump, was promptly diagnosed with advanced non-small-cell lung carcinoma in Septem…

oncologypalliative carepantoprazole

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