Coroner's Finding: CZEKAJLO Helena

69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots) in a person with schizophrenia and dementia

Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. Staff performed Heimlich maneuver and back slaps, but should have immediately called a registered nurse and emergency services after initial attempts failed. The coroner identified several deficiencies: inadequate staffing (one carer supervising 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 implemented improvements including increased registered nurse presence, dedicated meal service staff, staff retraining in choking management, and equipment maintenance protocols. The coroner made no formal recommendations as the facility demonstrated appropriate corrective actions.