Coroner's Corner - Inquest into the death of Paul Joseph Milward Coroner's Corner - Inquest into the death of Paul Joseph Milward

Coroner's Corner - Inquest into the death of Paul Joseph Milward

24 September 2018 | Health Sector

Date of Findings: 5 June 2018
Coroner: John Lock
Inquest Place: Ipswich
Date of Death: 31 August 2015

The inquest into the death of Mr Paul Milward addressed the systemic issue of choking deaths of persons in care with a disability. With input from the Office of the Public Advocate, the Deputy State Coroner has recommended that the National Disability Insurance Scheme (NDIS) quality assurance framework factor in strategies to deal with this issue.

There are also recommendations directed broadly at residential aged care and disability care providers to ensure that care plans for persons at risk of choking are regularly reviewed by staff and updated where required, including with the assistance of medical practitioners.

Factual Summary

Paul Joseph Milward was a 53 year old resident at Bundaleer Lodge, an aged care residential facility in Ipswich. Mr Milward was unable to live independently or with family following the onset of Huntington’s disease.

Mr Milward required assistance with activities of daily living and mobility, and specifically required assistance and supervision when eating, on the basis he was at risk of choking on food and fluids. Due to the effects of Huntington’s disease, Mr Milward at times exhibited aggressive and uncooperative behaviour.

On the morning of 31 August 2015, nursing staff brought Mr Milward his breakfast which included two pieces of bread cut into triangles. The staff member closed the door and left Mr Milward to eat the bread, as Mr Milward did not like to be disturbed when eating. When the staff member returned to his room some two hours later, Mr Milward was unresponsive. An autopsy examination found the cause of death was due to choking.

Background - Involvement of the Office of the Public Advocate

The Office of the Public Advocate (QLD) released a report in February 2016 following a review of the deaths of 73 people with disabilities who died in care in Queensland.

Choking on food/food asphyxia was identified as one of the leading causes of death. The report outlined a number of recommendations to help prevent death from choking on food, including:

  • Proper development and strict compliance with mealtime management plans.
  • Regular review of those plans.
  • Increased understanding and training for staff in relation to their roles for ensuring plans are complied with.

Findings with respect to Mr Milward’s care

The Coroner made the following factual findings in relation to the care provided to Mr Milward at Bundaleer Lodge:

  • Mr Milward was a difficult resident to manage given his cognitive impairment, challenging behaviours and physical difficulties.
  • These issues were recognised and care plans were put in place by Bundaleer Lodge, including care plans for food and fluid intake given Mr Milward had been assessed as a swallowing/choking risk.
  • Unfortunately staff did not strictly apply the care plans. While there had been no previous incidents involving Mr Milward choking, on this particular occasion he had been left alone in a closed room with a sandwich and not checked on for two hours. During that time, he choked on the sandwich and died.
  • It is apparent that the individual staff member involved was attempting to balance Mr Milward’s needs for safety and autonomy in the context of her understanding that she was to feed Mr Milward with soft and moist food, but was permitted to allow him to eat his sandwich on his own, there having been no observed problems in the past with soft bread.

Formal Recommendations

The Coroner found that the steps taken by Bundaleer Lodge following Mr Milward’s death in order to mitigate the risk of choking deaths of its residents were consistent with the recommendations previously suggested by the Public Advocate. As such, no further recommendations were directed to Bundaleer Lodge.

Rather, the recommendations made had a broader application, expressed to be for the consideration of all those engaged in the aged care industry and other carers providing residential services to similarly vulnerable people.

These recommendations are:

  • Choking deaths of persons in care with a disability be specifically acknowledged as a systemic issue, and strategies to manage, monitor, review and report on this particular issue should be built in to the NDIS quality assurance and reporting framework.
  • All staff involved in the provision of care to residential aged and disability care residents be informed of any material change to a resident’s care plan prior to the commencement of their next shift.
  • Residential aged and disability care residents’ care plans be subject to routine review at least three monthly and sooner if health or other personal circumstances have changed.

Residential aged and disability care residents with conditions that affect their ability to swallow should undergo regular medical examinations,  assess their respiratory health in order to identify and treat aspiration pneumonia.

Melissa Carius

Melissa Carius

Senior Associate