Finding into death of Tracie Lyndal Markwick

54y · Female·choking on a food bolus in a woman with an intellectual disability and other medical comorbidities

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-moderate choking risk, requiring small food pieces, close monitoring, and 30-minute post-meal positioning. Staff at the centre appropriately responded with back thrusts, manual extraction attempts, and CPR when choking occurred. The coroner found no preventability issues and commended staff response. Clinical lessons include: maintaining vigilance with dysphagia patients despite precautions, ensuring mealtime supervision protocols are consistently followed, and recognising that some choking episodes in high-risk individuals may be unpreventable despite appropriate care structures. The case highlights the importance of comprehensive assessment and documented management plans in disability care settings.