Finding into death of Nerilee Elizabeth Barfoot

30y · Female·Global cerebral ischaemic injury and bronchopneumonia following PEA arrest in a woman with Lennox-Gastaut Syndrome

A 30-year-old woman with Lennox-Gastaut Syndrome, a severe treatment-resistant epilepsy, died following cardiac arrest at a disability residential care facility. She was found entangled in a swing seat armrest on 7 April 2013 and died six days later from global cerebral ischaemic injury. The coronial investigation found no evidence that supervision was inadequate at the time of the incident. The coroner could not determine whether she experienced cardiac arrest during a seizure or whether entanglement caused hypoxia leading to arrest. Prior to this death, the swing seat had not been perceived as hazardous. Following the incident, Focus implemented improved risk assessment procedures for garden furniture and enhanced occupational health and safety protocols.