Death by Choking or Dysphagia: A Review of Coronial Findings (Australia and Canada): A Picture of Preventable Death, Non-adherence to Written Recommendations, and Lack of Appropriate Supervision

Shaun McCarthy; Bronwyn Hemsley; Fiona Given; Hannah Williams; Susan Balandin

Death by Choking or Dysphagia: A Review of Coronial Findings (Australia and Canada): A Picture of Preventable Death, Non-adherence to Written Recommendations, and Lack of Appropriate Supervision

J Law Med. 2022 Jun;29(2):400-405.

Authors

Shaun McCarthy¹, Bronwyn Hemsley², Fiona Given³, Hannah Williams⁴, Susan Balandin⁵

Affiliations

¹ Director, University of Newcastle Legal Centre, New South Wales, Australia.
² Head of Speech Pathology, University of Technology Sydney, New South Wales, Australia.
³ Research Associate, University of Technology, Sydney, New South Wales, Australia.
⁴ Research Associate, The University of Newcastle, New South Wales, Australia.
⁵ Adjunct Professor, University of Technology, Sydney, New South Wales, Australia.

PMID: 35819380

Abstract

Choking and aspiration pneumonia are a leading cause of preventable death for people in residential care in Australia. In Victoria, in 2018-2019, 59% of deaths of persons in residential care that were referred to the coroner were from aspiration pneumonia. In 2016-2017, in New South Wales, the leading cause of death in people with disability living in residential care was pneumonitis caused by solids and fluids in the lungs. Such deaths are closely linked with swallowing problems (dysphagia) and people with cognitive impairments and multiple health issues, including mental health issues, are most at risk. This commentary focuses on coronial inquests where coroners' findings have identified dysphagia or aspiration pneumonia as a cause of death or a contributor to a person's death. It also includes a summary of the recommendations by coroners which highlight processes that should be implemented to improve the safety of people with dysphagia.

Keywords: Choking; aspiration pneumonia; disability; dysphagia; mealtime assistance.

Publication types

Review

MeSH terms

Airway Obstruction* / complications
Cause of Death
Deglutition Disorders* / etiology
Humans
Pneumonia, Aspiration* / complications
Victoria