C, a child aged 14 - Non-inquest findings

14y · Female·Hypoxic-ischaemic encephalopathy due to choking on food, as a consequence of foetal alcohol syndrome

A 14-year-old girl with foetal alcohol syndrome, autism, and intellectual impairment died from hypoxic-ischaemic encephalopathy following choking on food during a community outing. She had been in state care since infancy and was largely tube-fed but was beginning to eat orally. Despite having an eating and drinking plan requiring supervision and small pieces of food, she accessed food from the front seat of a vehicle and choked. Clinical lessons include: the critical importance of staff understanding and compliance with individualised eating/swallowing plans for people with intellectual disability; the need for designated health coordinators in residential care; hand-held health records to improve communication between providers; and training in choking prevention, food preparation, and emergency response. The coroner found systemic improvements needed but no significant shortcomings in the Department's care provision.