Finding into death of Silvie Marion Burton

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

An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actual events. There was a 50-second delay before attempting to relieve the obstruction, and a further delay (approximately 4 minutes) before emergency services were contacted. First aid response did not align with St John Ambulance Victoria guidelines, which recommend immediate emergency contact before or concurrent with back blows and chest thrusts. The coroner found care 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 vigilant mealtime supervision for vulnerable residents with cognitive impairment.