Coroner's Finding: NISCO Sophia Alessia

16y · Female·upper airway occlusion due to aspiration of a foreign body (disposable latex glove) with contributing cerebral palsy

Sophia Nisco, a 16-year-old with severe cerebral palsy and intellectual disability, died from airway obstruction after aspirating a disposable latex glove at a respite care facility. She had documented oral fixation behaviours—putting objects indiscriminately in her mouth—which was recorded in her care plan but not adequately communicated to all staff. While at the facility, she required constant observation but was left unattended in a playroom when carers attended to another child with higher-risk behaviours. She relocated to a bathroom where disposable gloves were accessible (on vanity, in bins, and dispensers) and aspirated one, leading to fatal airway obstruction. The coroner found supervision was inadequate, care plans were insufficient in identifying and communicating risks, and there was a staffing shortage (no carer overlap during handover). Preventability hinged on constant observation and environmental control of hazards.