Phillip Charles Hodges: Man’s death at Moran Residential Aged Care preventable

The horrified daughter of a Roxburgh Park nursing home resident received a frantic phone call from staff saying her dad was choking to death.

Panicked and untrained staff at a Roxburgh Park nursing home failed to “effectively manage” a choking incident resulting in the death of an elderly man, a Victorian coroner has found.

Coroner Audrey Jamieson this month handed down her findings into the “preventable” death of Moran Residential Aged Care resident Phillip Charles Hodges.

She found aged care home staff failed to recognise Mr Hodges was unable to swallow while being fed, leading to him choke. Further, staff were unable to manage the situation, leading to his death.

After suffering multiple strokes and with other “significant health issues”, including Alzheimer’s, Mr Hodges began living at the aged care home in 2012.

The 72-year-old, who was unable to move or speak, was visited by his daughter and two grandchildren about 3.30pm on April 16, 2017.

They shared their Easter Sunday lunch with him, feeding him “small” spoonfuls of mashed potato and vegetables. But, with a “sweet tooth”, he ate all of the tiramisu.

The family enjoyed “quality time” together before they left about 5pm.

A short time later, while still driving home, his daughter answered a call from a frantic woman.

“Do we resuscitate, do we resuscitate? Your father’s choking! He’s dying! Do we resuscitate?,” to which she replied “yes” and immediately turned her car around and rushed back to her father.

Entering the lounge where she had left him not an hour before, she saw his body on the floor, covered by a white sheet.

The findings show a registered nurse had been helping Mr Hodges eat his dinner of pureed meat and soft boiled vegetables when he “started gagging” and “choking” on the vegetables about 5.30pm.

The nurse struck him on the back a few times to try to “expel the food” before activating an emergency buzzer.

Staff attempted to clear Mr Hodges’ mouth and throat with suction equipment, but realising their attempts were unsuccessful they called triple-0 and began CPR — 13 minutes after he began choking.

Moran Roxburgh Park

Paramedics arrived about 5.30pm and took over, but Mr Hodges was pronounced dead at 6.10pm.

A report prepared for the coroner found it may have been likely he was not hungry after his earlier meal and being given a ‘Sustagen’ before his dinner, but the nurse was not trained to recognise that he may have been “pooling his meal in his mouth” and continued to feed him.

The coronial investigation found the Australian Aged Care Quality Agency (AACQA) did not specify what training was required for accreditation of aged care facilities at the time, while the fact staff were not trained in “safe feeding” for residents with dysphagia, including Mr Hodges, was conceded by Moran in the court documents.

There were also concerns that Mr Hodges had not seen a speech pathologist since 2014, with one expressing that his health records showed conditions which could lead to “potential for silent aspiration” but this was undiagnosed and so his diet consistency was not amended.

Coroner Jamieson found Mr Hodges’ death was “preventable”, with the training shortfall and inadequacies in dealing with the incident causally connected with his death.

She noted she would be “remiss in her duty” if she did not make public policy considerations regarding aged care workers having “the same or similar clinical skills and knowledge as those in an acute hospital environment”.

“By and large, residents in aged care facilities are at high risk of developing life-threatening complications for various reasons including, but not limited to, advanced age, comorbidities or other conditions which render them prone to medical emergency,” she said.

A coroner has recommended more extensive training to prevent such a tragedy occurring again

She deemed it “unacceptable” that aged care staff were not legally required to undergo training to effectively manage medical emergencies.

According to the documents, Moran group’s Performance and Risk Manager, Adrian Sheridan, said it had since implemented a range of improvements including “swallowing screening” within the first two hours of admission, as well as staff education and training about respiratory illness and dysphagia.

While commending the actions, Coroner Jamieson said more specific training was required.

Taking into account the work already being done as a result of the Royal Commission into Aged Care Quality and Safety, published on February 26, 2021, she recommended the federal and state health departments created a legislative mandate requiring annual drills for residential aged care staff “to enable the staff to develop the necessary skills to abate the medical emergency risks presented by choking incidents”.

She also recommended the departments include training modules to cover emergency procedures in choking incidents as part of standard first aid response training for residential aged care.

Her third recommendation was for the departments to devise or develop a training module for aged care staff to safely provide feeding assistance at all times to residents with modified texture diets.

The federal government is responsible for the regulation of private residential aged care, including clinical care and management.

A Victorian Department of Health spokesperson said the state had a “long standing practice of authoring and contributing to a range of educational materials and training resources around high risk clinical areas of residential aged care”, including choking.

The federal government was contacted for comment.