Paul Milward was a 53 year old man who suffered from Huntington disease and lived at a residential aged care facility.

His care plan required that he be given soft food and that he be on supervision while eating, due to his risk of choking. On 31 August 2015, Mr Wilward was found dead on his bed after choking on his breakfast.


Mr Milward resided at an aged care facility ('the Facility). He had a history of depression, gastro-oesophageal reflux disease and asthma. He also had Huntington's disease, requiring assistance with daily activities like mobility. He also required supervision when eating because he was at risk of choking on food. His care plan required that he be on a minced moist diet and thin fluids.

At around 8am on 31 August 2015, Mr Milward was served breakfast including bread. He was left alone in his room to eat with the door shut. The inquest heard that this was because he did not like to be disturbed when eating. It also heard that Mr Milward had a history of aggressive and sometimes, uncooperative behaviour due to the effects of his Huntington's disease. Approximately two hours later, he was found without any movement and a piece of bread in his mouth. He was confirmed dead shortly after, aged 53. An autopsy revealed that he died due to choking.

In February 2016, the Public Advocate of Queensland published a report that stated that lack of compliance with mealtime management plans and the issue of non-supervision are the two key factors leading to choking deaths. The Public Advocate was given leave to appear before the Coroners Court where it made submissions to this effect in regard to the case of Mr Milward.

Submissions of Independent Expert

An independent expert acknowledged the difficulties that would have been experienced by staff in caring for Mr Milward. She noted that it would have been hard for staff to carry out care plan interventions if Mr Milward did not want them to occur. However, she opined that Mr Milward's care was negatively impacted by staff not complying with his care plan. She also stated that it was 'unacceptable' that Mr Milward's carer took two hours between serving him breakfast and returning to check on him. She recommended mandatory annual training for staff on modified diets for residents and education on the importance of providing supervision to such residents.

Submission of the Facility

The Facility submitted that compliance with Mr Milward's mealtime management plan was potentially a result of the staff members' fear and inability to manage his behaviour. It submitted that it had changes to its operation and policies as a result of Mr Milward's death including mandatory training of staff and assessment of the supervision requirements of residents.

Findings and Recommendations

The Deputy State Coroner found that the deceased was a difficult resident to manage given his cognitive impairment, challenging behaviour and physical difficulties. It was 'apparent', the Deputy State Coroner stated, that the staff member who served breakfast to the deceased, was attempting to balance his needs for safety and autonomy. However, he also found that his food intake plan was not strictly applied.

The Deputy State Coroner made the following recommendations:

  1. That choking deaths of persons with disability and in care, be specifically acknowledged as a systemic issue and that strategies to address it be built into the NDIS (National Disability Insurance Scheme) quality assurance and reporting framework;
  2. That all staff involved in the provision of care to persons in residential care be informed of changes to their care plans prior to the commencement of their shift;
  3. That residents' care plans be reviewed at least every three months and sooner if circumstances change;
  4. That residents with swallowing difficulty undergo regular medical examinations to assess their respiratory health.