Finding into death of Saba Pietropaolo

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. On the day of death, family members requested coffee and staff required a 'Dignity of Risk' consent form to be signed, which was completed after the fatal incident. The Aged Care Quality and Safety Commission found the facility's response and analysis appropriate. The coroner concluded the death was an unintended consequence of consuming thin liquids despite dietary restrictions, but found the care provided was reasonable and appropriate. Key clinical lesson: careful documentation and timing of consent for dietary risks in aged care, ensuring family understanding of dysphagia management protocols.