In October 2015, an inquest1 was held into the death of an aged care resident, Mr Brian Keith Wood, after he choked on some toast.


Mr Wood was an 84 year old man who suffered from dementia and resided in an aged care facility. On 1 January 2011, Mr Wood was eating his breakfast when he began to choke on some toast. The carers at the facility noticed Mr Wood choking and rendered assistance, notifying the nurse on duty.

The nurse and care staff endeavoured, without success, to clear Mr Wood’s airway by striking his back and attempting to remove the food from his throat using a suction kit. Neither the nurse or care staff performed CPR on Mr Wood. An ambulance was then called but no resuscitation attempts were made while the staff awaited the ambulance’s arrival. Mr Wood passed away shortly thereafter.

At the inquest, it was revealed that Mr Wood had been placed on a ‘soft diet’, as he had difficulties chewing. He was permitted to eat toast but with no crust, and this had been properly communicated to staff. On the morning of the incident, Mr Wood was provided a meal in accordance with his diet plan. An autopsy revealed foreign material obstructing Mr Wood’s large airways.

When, during the inquest, the aged care facility was questioned about why CPR was not performed, it was revealed that the facility did not have a policy that permitted staff to undertake CPR on residents. The nurse on duty commented that she believed CPR would have done more harm than good to Mr Wood, being an older, frail man.

It was also significant that, prior to the incident, Mr Wood had not made an advanced health directive, and it was neither recorded nor known whether or not he would have wished to be resuscitated.


The Coroner was ultimately not critical of the aged care facility’s policies or practices regarding the food provided to Mr Wood, and the failure to perform CPR. the Coroner noted, however, that it is desirable for there to be some guidance for registered nurses in balancing the risks and benefits associated with the performance of CPR.

The Coroner found that the softened toast Mr Wood was provided on the day of the incident was entirely appropriate to his needs. The Coroner also found that the aged care facility’s policy and practice surrounding CPR was consistent with national standards for resuscitation, in that the decision to resuscitate should be left to properly qualitied staff members, in lieu of an advanced directive.

The Coroner was satisfied that in order to reverse the obstruction of Mr Wood’s airways, significant medical intervention was required of a nature that the nurse and care staff could not have been expected to provide. The Coroner noted that the performance of CPR would have been futile, and therefore nothing the staff did or failed to do would have been likely to prevent Mr Wood’s passing.

Since the inquest, the aged care facility has provided training on CPR to its staff and nurses, however whether CPR is performed still remains a clinical decision where the individual circumstances of each case must be considered.


The inquest emphasised the importance of residents or their representatives engaging in discussions to consider the appropriateness of an advanced health directive, however uncomfortable such discussions may be.

The Coroner also noted it is desirable that clinicians working in the aged care setting be supported with guidance and policies that assist them in their decision-making when confronted with an emergency situation.