Coroner's Finding: NOONAN Ricky Dale

54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking

A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to a patient with poor dentition and sedating medications increasing aspiration risk; inadequate continuous monitoring of the seclusion room by CCTV despite a monitor displaying real-time footage being immediately available to nursing staff; failure to communicate with the patient every 15 minutes as required; and haphazard observation documentation not reflecting actual practice. The CCTV footage showed the patient collapsed motionless for 11-12 minutes before detection. Earlier detection via continuous CCTV monitoring would likely have prevented death, and supervised feeding would have prevented the initial choking incident entirely. The new practice of continuous face-to-face observation outside seclusion rooms has since been implemented.