Coroner's Finding: Hunter, Feryne Gaylene

75y · Female·Airway obstruction due to aspiration occluding a permanent tracheostomy

Feryne Gaylene Hunter, aged 75, died from airway obstruction due to aspiration into her permanent tracheostomy. She had a history of subglottic stenosis, asthma, and gastro-oesophageal reflux disease with a hiatus hernia. Despite district nursing care three times weekly and two ambulance attendances on 11-12 September 2017, Mrs Hunter consistently refused assessment and hospital transport. Paramedics correctly applied capacity assessment criteria (VIRCA) on both occasions. The coroner found no preventable failures in clinical care or paramedic actions. However, documentation of refusal assessment could have been more comprehensive regarding risks and alternative pathways. The underlying clinical deterioration—coughing up clots, tracheostomy blockages, and progressive unwell state—occurred despite appropriate monitoring and advice to seek help.