Paul Milward was aged 53 at the time of his death on 31 August 2015 and resided at an aged care residential facility.

Mr Milward suffered from Huntington's disease, depression, gastro-oesophageal reflux disease and asthma.  He was on numerous medications.  It was noted in Mr Milward’s aged care record that he required assistance with activities of daily living and mobility due to involuntary movements (chorea) as a result of Huntington's disease.  He also had cognitive impairment.  There was a history of aggressive and at times uncooperative behaviour due to the effects of Huntington’s disease.

The aged care provider records indicated that Mr Milward needed supervision when eating, on the basis he was at risk of choking on food.  A speech pathologist had recommended that he be provided a minced moist diet and thin fluids, with a view to upgrading to other food types as appropriate, if increased supervision was able to be provided at meal times.

At around 8am on 31 August 2015, staff brought Mr Milward his breakfast, partly consisting of two pieces of bread cut into triangles with butter and jam.  A staff member assisted him to change before assisting him back to bed and leaving him to eat his bread and jam.  The staff member closed the door as Mr Milward did not like to be disturbed when eating.

Approximately two hours later the staff member returned to the room and found Mr Milward lying in bed on his right side with his left hand raised to his face.  There was a piece of bread in his mouth and bread on the bed underneath his face.

An autopsy examination found the cause of death was due to choking.

The Coroner cited a recent report of the Public Advocate of Queensland that identified lack of compliance by support staff with mealtime management plans and periods of non-supervision as the two key factors leading to choking deaths.

An expert witness acknowledged the tension in this matter between the risk management strategies that ought to have been adopted by the aged care provider and the efforts the provider had taken to respect Mr Milward’s autonomy.

Whilst the Coroner elected not to refer to the matter to Aged Care Quality Agency, we anticipate that aged care providers will also need to have regard to any strategies proposed by the National Disability Insurance Agency (NDIA) to manage and monitor persons with dysphagia.

To read the Coroner’s findings, click here .