Finding into death of Katrina Mary West

56y · Female·Hypoxic ischaemic brain injury due to upper airway obstruction by food bolus

A 56-year-old woman with intellectual disability and acquired brain injury died from hypoxic ischaemic brain injury following upper airway obstruction by a food bolus while eating dinner in supported accommodation. She was eating unsupervised in a separate unit while two disability support workers prepared meals in another unit. A resident found her choking and had to seek help. Although staff commenced CPR immediately upon discovery, the prolonged anoxia resulted in severe brain injury. Clinical lessons include: the importance of individualised risk assessment for choking in people with intellectual disability, particularly regarding meal supervision; the need for staff to be physically present during mealtimes for clients with communication or swallowing difficulties; and systems to enable rapid staff alerting in emergencies. The coroner found no formal choking risk documented despite family accounts of the patient needing reminders to chew properly and prior gagging episodes.