95y · Female·asphyxia due to glottic obstruction by food
…on rings. Care staff did not verify dietary requirements despite seeing inappropriate food textures. When choking began, the registered nurse incorrectly attributed coughing to chest infection rather than recognised cho…
39y · Male·Choking on a food bolus
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan a…
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 …
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…
72y · Male·asphyxia due to upper airway obstruction due to choking on food
A 72-year-old man with acquired brain injury, seizure disorder, and dysphasia died from asphyxia due to choking on food while eating eggs and ham on toast at a disability care facility. He had no documented swallowing…
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed…
81y · Female·Complications of choking on a food bolus in a woman with dementia
Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus…
42y · Female·Choking on a food bolus
Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a s…
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…
21y · Female·hypoxic brain injury due to choking on food, with Bardet-Biedl Syndrome as a con…
…l Syndrome causing intellectual disability and developmental delays, died from hypoxic brain injury after choking on a Jaffa lolly while being driven in a minibus by a disability support worker. Critical clinical lesson…
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…
51y · Female·Aspiration pneumonia
…r swallowing ability presented to hospital with a cough and was admitted on 15 December 2017, following a choking incident at her group home. She died on 23 December 2017 from aspiration pneumonia. The Disability Servic…
43y · Female·choking on a food bolus
Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her …
56y · Female·Hypoxic ischaemic brain injury due to upper airway obstruction by food bolus
…a separate unit while two disability support workers prepared meals in another unit. A resident found her choking and had to seek help. Although staff commenced CPR immediately upon discovery, the prolonged anoxia resul…
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…
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…
28y · Female·asphyxia due to neck compression or strangulation
…lation as a risk factor for homicide. Dobson had a documented pattern of violence against women involving choking and throat compression, yet continued to evade serious legal consequences. At the time of Ms Eaton's deat…
57y · Male·Aspiration of gastric content (due to choking on food)
…rence to individualised mealtime guidelines developed by speech pathologists, and prompt recognition that choking may trigger agonal seizures rather than primary epileptic events. Enhanced staff training on aspiration p…
69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…
…vising meals alone), lack of speech pathology assessment despite risk factors, failure to use appropriate choking management techniques (lateral chest thrusts), and non-functional oxygen equipment. The home subsequently…
19y · Male·aspiration of latex glove; intellectual disability
…-level support (level 5). Despite staff awareness of this risk, insufficient supervision was provided and choking hazards (latex gloves) were inadequately secured. Gloves were stored in accessible locations and used bin…
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