A Solemn Reminder

I wanted to tell you a very sad story that occurred recently.

A truly wonderful aged care facility who offers the absolute best care for their residents recently had a tragic event.

An elderly resident had been assessed by the facility’s speech pathologist who had recommended a diet modification. This is certainly part of our role in caring for those in the population who have swallowing issues – ageing residents and those with a disability often fall into this category.

The gentleman had just finished eating his dinner. Walking away for the table, he attempted to cough. A nurse was standing behind him as he began to collapse. He was choking on a mouthful of his dinner. Despite CPR being immediately and consistently administered until the ambulance arrived, the gentleman died.

This is a shocking tragedy. This gentleman lost his life. Whilst the resident did not have any family, his fellow residents and the staff at the facility who witnessed this incident, have all been very significantly affected. The error was that the dinner prepared for him did not consistently follow the speech pathologist’s texture modified recommendations. Some of the meal was too big for him to chew and swallow safely.

The staff member who prepared this gentleman’s meal will carry that burden with them forever. She was immediately dismissed.

Since 1987, I’ve been providing education about swallowing safety and dysphagia diet food and fluid modifications. In that time, I have had a couple of staff members who queried the need for education, telling me that they have never seen anyone under their care choke.

One can never assume that this awful situation will not occur. This tragedy is a poignant reminder of the need to support both residents and staff.

Ensuring staff have the proper training in managing the resident’s safe swallowing and following, to the letter, the recommended food and fluid modifications, for the sake of the residents and staff, could not be more important.

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