A woman with dementia choked to death at her Tasmanian nursing home after staff missed a warning sign that a coronial review found may have identified her as being at high risk of choking.
Judith Mary Dodd, 86, died at Yaraandoo Nursing Home in Somerset on August 4, 2024, after being served curried egg sandwiches for dinner.
A carer found her slumped in her wheelchair and unconscious around 5:25pm after she failed to come out for her usual after-dinner cigarette.
Staff started CPR and paramedics continued resuscitation attempts, but her airway was full of bread and egg and could not be cleared. She was declared dead at 5:55pm.
Coroner Madeleine Wilson found Dodd died from a foreign body airway obstruction, with dementia the most significant risk factor.
Dodd’s son told the coroner his mother would eat very quickly and often ignored advice from him and staff to slow down.
He said she would be “shovelling the food in her mouth and hurrying so she could have a cigarette”.
Her son said he visited on the afternoon of her death and took her outside for a cigarette, with everything appearing “fine and relatively normal”.
A coronial nurse who reviewed Dodd’s care found staff carried out appropriate swallowing and diet assessments but did not always follow them up on time.
A speech pathologist had recommended Dodd avoid bread, toast and mixed-consistency foods.
But Dodd repeatedly completed formal “dignity of risk” assessments so she could continue eating them – a choice the nurse said supported her independence.
A swallowing screening completed on July 7, 2024, did not include a choking episode from weeks earlier, on June 21, when Dodd choked on chips and needed back thrusts.
The nurse said including that incident “would have increased” Dodd’s score, “potentially placing her in the high-risk category and potentially altering the management strategies and recommendations”.
Wilson made no formal recommendations.
She said aged care assessments should be completed on time and take into account all recent clinical information, while a resident’s resuscitation status should be clearly documented and readily accessible.
