Inquest into the death of Bridie Gilligan

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

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 injury and death on 3 May 2021. The coroner found the death preventable, identifying critical system failures: incomplete dysphagia assessment without follow-up, lack of collaboration between speech pathology and dietetics, inadequate support worker training on soft diet standards, and NDIS structural design preventing information sharing between disability providers and health services. While the individual support worker was not found at fault, essential clinical lessons include: completing allied health assessments, providing direct professional training to support workers on clinical terminology, ensuring multidisciplinary collaboration with documented recommendations, and recognizing that genetic conditions causing dysphagia require constant, not episodic, risk management.