Coroner's Finding: CHILDS Hayden William

77y · Male·hypoxic-ischaemic encephalopathy and cerebral infarction due to upper airway obstruction by foreign body (handkerchief) with contributing right lower lobe suppurative bronchopneumonia, cardiomegaly and dementia

A 77-year-old man with advanced dementia died from hypoxic-ischaemic encephalopathy caused by upper airway obstruction from a handkerchief. An agency carer placed a handkerchief in his breast pocket during morning care, unaware of his known propensity to place objects in his mouth. The handkerchief migrated into his airway by late evening. Nursing staff performed suctioning with a hard plastic device, which compressed the handkerchief further into the airway, causing complete obstruction and severe hypoxia. The death was preventable through: proper communication of at-risk behaviours to agency staff via prominent care plan documentation; removal of potentially harmful items from the resident's wardrobe; and visualization of the airway before suctioning. The nursing home's care plan inadequately highlighted this critical choking risk, and agency staff were not required to review it.