People with dementia are prone to experiencing problems with eating and drinking. A recent coronial investigation has highlighted the need for aged care organisations to implement policies and procedures both to ensure their residents are protected from choking hazards and are adequately attended to in an emergency.


Mrs Margorie Hall was a 75-year-old woman suffering from dementia and short-term memory impairment. At the time of her death she was residing at Bupa Aged Care Edithvale (Bupa), where she had been living for 3 years.

Mrs Hall had problems chewing and swallowing solid foods and aspirating thin fluids when drinking. Consequently, she was placed on a diet consisting of vitamised thickened fluids. Various entries in Mrs Hall’s progress notes and care plan stated that she needed full assistance, supervision and encouragement when eating meals. Also, that because of her tendency to take food from other residents and her risk of choking, it was noted that Mrs Hall should never be left unattended in the dining area while other residents had food.

On 7 October 2013, Mrs Hall was observed by a staff member to be eating a slice of bread in a corridor. She began gasping for breath and several staff members were involved in attempting dislodge the food from her throat by performing abdominal thrusts and using a suction machines. Mrs Hall resisted this help, and quickly fell unconscious. As a ‘not for resuscitation’ order was in place, no resuscitation was initiated nor an ambulance called. A doctor was called shortly thereafter who declared Mrs Hall dead.

Bupa’s response

Following this incident, Bupa provided emergency response training, including cardiopulmonary resuscitation (CPR), to relevant staff at the facility. After an internal review, a number of changes were made to reduce the risk of a similar incident occurring, including:

  • emergency response training for staff;
  • implementing training in relation to dysphagia and choking in the elderly;
  • a door being installed in the dementia unit to restrict residents from accessing the kitchen area, reducing the risk of their being able to access foods and fluids;
  • purchasing modified meal trolleys with special zipped covers for use in the dementia unit;
  • conducting an audit of the nutrition and hydration arrangements for residents and preparing a handover tool for staff to highlight residents’ risks of choking; and
  • holding a staff meeting to communicate all relevant changes.

Bupa also updated its admission process to ensure that the assessment chart records a resident’s risk of choking.

The Coroner’s recommendations

The Coroner reviewed Bupa’s response to the incident and made a number of additional recommendations.

Emergency response, including CPR training, should be undertaken annually by all Bupa facilities

In response, Bupa undertook a review of the existing schedule for education, and acknowledged that it would be beneficial for staff to have annual dysphagia and emergency response training as a combined course. Additionally, Bupa appointed a Nurse Manager for Clinical Education and Development. The combined training is scheduled to be rolled out at 68 aged care homes in 2016.

All changes made to Bupa’s Edithvale dementia unit be implemented at all other Bupa Aged Care dementia units

In addition to complying with this recommendation, Bupa issued a ‘Safety Alert’ to all facilities which required the scheduling of education for all staff who supervise and provide food to residents, with a particular focus on dysphagia and choking in the elderly.

Bupa also identified an opportunity to establish a business-wide process for handover communications that contain specific resident information and risk alerts. This subsequently led to the formation of a group of ‘clinical leaders’ to review best practice literature and contemporary practice to develop a handover tool specifically for the aged care industry.

Review the process for adding and updating information to any ‘Plan of Care’ document

To ensure care needs are clear and legible, Bupa will now require care plans to be re-printed during the three monthly review (when changes have been made in the preceding three months) and whenever multiple changes are documented.


The unpredictable nature of residents suffering from dementia requires aged care organisations to be vigilant in ensuring that risks are minimised.

The investigation provides a timely reminder to all aged care organisations, particularly those with dementia units, to review their own emergency response procedures and training and care plan documentation to ensure they comply with what is considered best practice.