Finding into death of Darren Carr Hannah

41y · Male·Upper airway obstruction from ingestion of dirt in an intellectually impaired man

Darren Hannah, a 41-year-old man with severe intellectual disability, autism, partial blindness and longstanding pica disorder, died from upper airway obstruction after ingesting large quantities of dirt in the backyard of his residential care facility. He was found unresponsive with his airway completely obstructed with mud and clay, and could not be resuscitated. Key clinical and systemic lessons include: (1) residents with documented pica require restricted access to potential hazards or constant supervised access to yards; (2) backyard hazards (dirt, soil) should be actively removed or minimised; (3) staffing levels must ensure continuous supervision during meal breaks—having only one staff member present created a supervision gap when the other was on lunch; (4) initial response delays occurred as staff activated a non-specific duress alarm rather than immediately calling emergency services. DHS implemented improvements including pica awareness strategies, behaviour support plan reviews, and duress alarm policy revision.