93 results
90y · Female·Choking
A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…
74y · Female·Acute renal failure complicating decreased oral intake in the setting of Angelma…
Susan June Mahoney, a 74-year-old woman with Angelman syndrome, died from acute renal failure secondary to progressively declining oral intake. From April 2025, staff observed reduced food and fluid intake with swallowin…
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
11y · Male·bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…
An 11-year-old Aboriginal boy died from bronchopneumonia and small bowel necrosis with perforation, following severe neurological impairment from an inflicted brain injury sustained at 8 months old. His parents delayed s…
42y · Female·Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange …
Bridie Gilligan, aged 42 with Cornelia de Lange Syndrome, profound intellectual disability and dysphagia, died from hypoxic brain injury after choking on a Yumbo burger at her SIL home on 29 April 2021. Her support worke…
73y · Female·Pneumonia (palliated)
Barbara Grace Bright, 73, died of pneumonia at Frankston Hospital. She was a long-term resident of specialist disability accommodation with cerebral palsy, dysphagia, epilepsy, and intellectual disability. From July 2024…
57y · Male·Complications following food aspiration in a man with multiple co-morbidities
Andrew Kursinskis, a 57-year-old man with intellectual disability, dysphagia, autism, epilepsy and pica, died from complications following aspiration of chicken schnitzel while living in supported disability accommodatio…
52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease
Christopher Kuric, a 52-year-old man with end-stage Huntington's disease residing in specialist residential care, died of aspiration pneumonia. He had documented swallowing difficulties managed by speech pathology and di…
54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…
Tracie Lyndal Markwick, a 54-year-old woman with intellectual disability and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-moderate cho…
60y · Female·Pneumonia with large pleural effusion
Ms Wood, a 60-year-old woman with Down syndrome, Alzheimer's disease and epilepsy residing in specialist disability accommodation, developed pneumonia with large pleural effusion and died in hospital. A speech pathologis…
62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…
John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…
8y · Male·prematurity-associated lung and bowel disease
Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…
75y · Male·aspiration pneumonia in the setting of Parkinson's disease and other medical com…
Ross Richards, a 75-year-old man with Parkinson's disease and dysphagia, died from aspiration pneumonia at Box Hill Hospital. He resided in specialist disability accommodation and had been assessed as high-risk for aspir…
39y · Female·aspiration pneumonia in the setting of general anaesthesia and colonoscopy for i…
A 39-year-old woman with cerebral palsy, dysphagia, and sleep apnoea died from aspiration pneumonia following a colonoscopy performed under sedation for investigation of rectal bleeding. She had known increased aspiratio…
64y · Female·Aspiration pneumonia in a woman with multiple comorbidities
A 64-year-old woman with severe intellectual disability and multiple comorbidities died from aspiration pneumonia while in specialist disability accommodation. She had documented dysphagia and aspiration risk identified …
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…
55y · Male·Aspiration pneumonia in the setting of cervical myelopathy, Down Syndrome and Al…
SW, a 55-year-old man with Down Syndrome, cervical myelopathy, and Alzheimer's Disease, died from aspiration pneumonia at a palliative care unit. He was admitted to hospital on 6 April 2023 after his treating neurologist…
53y · Female·Bronchopneumonia on a background of cerebral palsy
Melissa Dibble, aged 53, died from bronchopneumonia in the context of cerebral palsy, spastic quadriplegia, cortical blindness and progressive dysphagia due to aspiration. She was admitted to The Alfred Hospital on 27 Au…
34y · Female·Aspiration pneumonia in a woman with cerebral palsy and Lennox-Gastaut syndrome
Hannah Gray, a 34-year-old woman with cerebral palsy and Lennox-Gastaut syndrome living in specialist disability accommodation, died from aspiration pneumonia. She had experienced progressive health deterioration over th…
85y · Female·Asphyxia due to upper airways obstruction by mucoid plugging of the upper airway…
Betty Cliffe, 85-year-old with intellectual disability and oropharyngeal dysphagia, died from asphyxia due to upper airway mucoid plugging on a background of cardiomegaly and heart failure. She was admitted to hospital o…
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