Coronial
QLDhome2026-02-03

Inquest into the death of Bridie Gilligan

42y · Female·Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange …

…a de Lange Syndrome, profound intellectual disability and dysphagia, died from hypoxic brain injury after choking on a Yumbo burger at her SIL home on 29 April 2021. Her support worker Margaret Lowry purchased the burge…

speech pathologydieteticscommunicationsystem
VIChospital2018-07-26

Finding into death of Maurice Benedict Costello

89y · Male·Complications of choking on a food bolus in a man with multiple medical comorbid…

Maurice Benedict Costello, 89, died from aspiration of a food bolus while eating on a geriatric ward three days after a fall. He had documented oropharyngeal dysphagia requiring supervision during oral intake. Speech pat…

geriatric medicinespeech pathologycommunicationsystem
VICaged care2014

Finding into death of Marjorie Hall

75y · Female·Aspiration of food in a woman with dementia

A 75-year-old woman with advanced dementia died from aspiration of food in an aged care facility. Despite being on a thickened diet and requiring full supervision due to documented swallowing difficulties and a tendency …

geriatric medicinespeech pathologysystemcommunicationrisperidone
QLDmental health2013-07-02

Justin

35y · Male·Choking due to impaction of soap in airway

A 35-year-old man with treatment-resistant depression and complex psychiatric presentation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted multiple suicides previously. Cl…

psychiatryintensive caresystemcommunicationrisperidone
SAmental health2000-09-22

Coroner's Finding: McQUINN Rosemary

68y · Female·glottic obstruction by food bolus

A 68-year-old woman with Huntington's disease, schizophrenia, and schizoaffective disorder died from glottic obstruction by food bolus while eating breakfast in a psychiatric hospital where she was detained under the Men…

psychiatrypathology
QLDhomeNew2026-02-03

Inquest into the death of Bridie Gilligan

42y · Female·Hypoxic brain injury due to choking on food, with Cornelia de Lange Syndrome con…

Bridie Gilligan, 42, with Cornelia de Lange Syndrome, intellectual disability, and dysphagia, choked on a Yumbo burger in her Supported Independent Living accommodation on 29 April 2021, suffering fatal hypoxic brain inj…

speech pathologydieteticssystemcommunication
VIChospital2023-11-24

Finding into death of Vikki Michelle Prenc

59y · Female·Asphyxial aspiration with upper airways obstruction by vomitus

…on, and contrary to institutional policy. When Ms Prenc arrested on 21 September from a reversible cause (choking), resuscitation was not attempted per the GOC. The coroner found Dr S.'s handling fell well below the sta…

general practicegeneral medicinecommunicationsystemondansetron
SAhospital2017-04-19

Coroner's Finding: ADAMSON Jean Anne

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

…e and psychiatry teams with subcutaneous fluid administration. On 6 November 2014, she had a vomiting and choking episode followed by a MET call. Following discussion with her sister, palliative care was initiated. She …

general medicinepsychiatrymorphine
NTcommunity2024

Inquest into the death of Domestic violence victim (Jingili Water Gardens)

20y · Female·Stab wound to the left mid-anterior of the chest in the context of multiple othe…

…e, failure to obtain witness statements, misidentification of the person needing protection, dismissal of choking allegations (a high-risk indicator), failure to issue Domestic Violence Orders when evidence existed, poo…

forensic medicineemergency medicinecommunicationsystem
SAhospital2016-09-12

Coroner's Finding: RAU Edward Morgan

77y · Male·aspiration pneumonia due to dysphagia on a background of dementia

…a secondary to dysphagia in the context of dementia. He was admitted to hospital on 29 October 2014 after choking on food. A speech pathologist assessed him as having significant aspiration risk requiring hospital admis…

geriatric medicinespeech pathology
VIChome2010-03-15

Finding into death of Terence Thomas Wilson

76y · Male·Upper airway obstruction by food bolus in a man with ischaemic heart disease

Mr Terence Wilson, aged 76, died from upper airway obstruction by food bolus while attending a family gathering. He had recently been diagnosed with ischaemic heart disease requiring bypass surgery and bipolar affective …

emergency medicinepsychiatrysodium valporate
VIChospital2018-09-13

Finding into death of Andrew Bond

47y · Male·Aspiration pneumonia in the setting of Down syndrome

…n swallowing function. He had oropharyngeal dysphagia since 2007 and Alzheimer's disease, with documented choking incidents in 2017. A speech pathologist recommended progression to pureed diet with thickened fluids. Alt…

geriatric medicinepalliative careamoxicillin/clavulanate
VIChospital2023-10-16

Finding into death of Adam Richard Greaves

48y · Male·Aspiration pneumonia complicating progressive degenerative neurological disorder…

…ate multidisciplinary support. From early 2022, his condition declined with frequent chest infections and choking episodes due to inability to clear secretions. After acute presentation on 28 October 2022, he received t…

emergency medicineneurology
VIC2021-09-22

Finding into death of Ruth Ridley

58y · Female·homicide of unknown causes

Ruth Ridley, aged 58, disappeared on 26-27 October 2019 during a camping trip with her husband Gary at Neil's Reserve, Walwa, Victoria. Her body was never located. The coroner found on the balance of probabilities that M…

VIChospital2012-09-18

Finding into death of Lorraine Therese Patrick

45y · Female·Aspiration pneumonia

A 45-year-old woman with Down syndrome, epilepsy, and non-verbalisation living in a high-care community residential facility died from aspiration pneumonia. She developed cold/flu symptoms on 2 January 2011, with a cough…

emergency medicineintensive caredelayceftriaxone
NSWhome2024-11-04

Inquest into the death of MR

4y · Female·hypoxic brain injuries

…despite resuscitation, suffered irreversible brain damage. Key clinical lessons include: recognition that choking on formula alone cannot explain the pattern of hypoxia observed; importance of escalation when concerning…

paediatricspathologydiagnosticdelay
VIC2014-10-07

Finding into death of Darren Carr Hannah

41y · Male·Upper airway obstruction from ingestion of dirt in an intellectually impaired ma…

Darren Hannah, a 41-year-old man with severe intellectual disability, autism, partial blindness and longstanding pica disorder, died from upper airway obstruction after ingesting large quantities of dirt in the backyard …

general practicepsychiatrysystemsupervisiondiazepam
ACThome2019-09-23

AN INQUEST INTO THE DEATH OFJANDY RENIA SHEA

27y · Female·neck compression (suicide by hanging)

…ntly reconciled with her estranged husband Chris despite a history of domestic violence, including a 2015 choking assault for which he was convicted. In the months before her death, Jandy experienced escalating intimate…

VICcommunity2021-10-01

Finding into death of Stuart Anthony Wills

45y · Male·Aspiration of food bolus, with cerebral palsy as contributing factor

Stuart Wills, a 45-year-old man with cerebral palsy and severe dysphagia, died from aspiration of a food bolus while receiving meal assistance at a supported accommodation facility. Prior to his death, a speech pathologi…

speech pathologyemergency medicineproceduraladrenaline
SA2003-09-25

Coroner's Finding: GOROSTIAGA Jessica

8y · Female·Closed head injury

An 8-year-old girl died from severe closed head injuries sustained when a bouncy castle (inflatable amusement structure) was lifted by a sudden whirlwind and collapsed. The child fell from the structure during its flight…

systemprocedural

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