Inquest into the Death of Mortensen

60y · Female·Aspiration of food in a woman with cerebral atrophy

Jytte Mortensen, a 60-year-old woman with multi-infarct dementia and schizoaffective disorder, died at Graylands Hospital from aspiration of food. She had documented dysphagia requiring a pureed diet and one-to-one supervision during meals. On 15 December 2001, Nurse Thompson fed her a lamington (soft cake) from the hospital kiosk, which was not on the approved pureed diet but was on the patient's Daily Kiosk Order Sheet. After supervision ended, the patient regurgitated the lamington, which aspirated into her airways. She had pre-existing cerebral atrophy, carotid artery stenosis, and ischaemic heart disease that made her vulnerable to rapid oxygen depletion. The coroner found the death was accidental and not preventable, but identified systemic communication gaps: the speech pathologist's puréed diet recommendation was not reconciled with the Daily Kiosk Order Sheet, and there was insufficient interdisciplinary communication between speech pathology, dietetics, and nursing staff regarding dietary consistency requirements for dysphagic patients.