Coroner's Court of Western Australia

Inquest into the Death of Brian Keith WOOD

Inquest into the Death of Brian Keith WOOD

Delivered on : 23 June 2016

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was 84 years old when he died on 1 January 2011 after choking on some food. At the time he had dementia and was residing at the Sarah Hardey House, a Uniting Church Home that was an aged care facility.  The staff members attending to him rendered first aid but no person performed cardiopulmonary resuscitation on him. The deceased did not have an advanced health directive, nor did he have a “not for resuscitation” order in place at the time of his death. 

The inquest focussed on the appropriateness of the food provided to the deceased prior to his choking episode, whether the administration of cardiopulmonary resuscitation was indicated and if so, whether it would have prevented his death.

At the material time, the attending clinician was of the understanding that cardiopulmonary resuscitation was not to be performed on the aged care residents. Court heard evidence that Sarah Hardey House has since the deceased’s death taken steps to clarify its policy concerning the performance of cardiopulmonary resuscitation on the aged care residents, and provided training. 

The State Coroner was satisfied that the food provided to the deceased was satisfactory and it followed that the deceased’s subsequent choking was a most unfortunate accident. The State Coroner further concluded that in order to reverse the occlusion of the deceased’s upper airways, significant medical intervention was required of a nature that nursing staff could not have been expected to provide. The State Coroner was satisfied the first aid which was applied to the deceased was appropriate and that cardiopulmonary resuscitation in these circumstances would have been futile.

The inquest highlighted the importance of community members engaging in discussions to consider the appropriateness of an advance health directive at a time when they have capacity. The State Coroner commented on the desirability for there to be guidance provided to registered nurses regarding the performance of cardiopulmonary resuscitation when the aged care residents’ wishes are not known.

The Coroner found the deceased died on 1 January 2011 as a result of upper airway obstruction in a man with a clinical history of dementia and death occurred by way of accident.

Catch Words : Aged care facility – Advanced Health Directive - Not for Resuscitation : - Accident

Last updated: 13-Feb-2024

[ back to top ]