Tragic accident: Parents not to blame for 11mo who died swallowing metal screw

The coroner said the toddler’s devastating outcome “could have been different” if Ambulance Tasmania provided its paramedics with advanced training in airway obstruction.

The death of a toddler who choked on a metal screw in Tasmania has been deemed a “tragic accident” by the Coroner who has urged for advanced training in airway obstruction. 

In May 2022, emergency services were called to a home in Hobart after reports of an 11-month-old choking on something. 

Two days earlier, the unnamed 11-month-old swallowed a Phillips-head metal screw and was unable to breathe. 

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An 11mo boy died after choking on a Phillips-head screw. Source: Google Maps

Toddler choked to death on Phillips-head screw

It’s believed the screw had come free from a child’s gate or the nearby wind-up blinds in the living room. 

He was taken to the Royal Hobart Hospital but tragically died three days later due to hypoxic brain damage. 

Coroner Robert Webster explained the medical team arrived seven minutes after the initial Triple Zero call and “did their best” to find the metal screw lodged in the boy’s throat. 

He added the care provided to the 11mo couldn’t be faulted, despite finding the metal screw increasingly difficult to locate. 

According to The Advocate, paramedics described the boy as turning blue, unable to breathe and making “agonal” respirations when they arrived on the scene.

He was intubated by the medical team - a move that goes against Ambulance Tasmania’s guidelines. 

The screw was able to be removed using forceps. 

“Locating the screw proved difficult because of the presence of vomit and blood, and the ventilation they were able to provide to [the baby] appeared to be effective,” the Coroner’s report found. 

Paramedics performed CPR on the baby and transported him to the Royal Hobart Hospital, where doctors learned he had hypoxic brain damage due to a lack of oxygen. He died two days later. 

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The Coroner's report said the toddler's death "could have been different" if paramedics had advanced training. Source: Tasmania Department of Health

Toddler’s death "could have been different" if paramedics had advanced training

The first doctor to treat the 11mo was Dr Tu Quyen Mai, who said the paramedics’ move to intubate the baby was “correct” despite it being against the rules.

“[The baby] had no chance of survival unless this procedure was performed, and by the time a doctor arrived, it would have been far too late,” said the report. 

Dr Mai added the outcome “could have been different” if paramedics had sufficient training in clearing airways. 

According to The Advocate, Ambulance Tasmania paused its new airway obstruction training during the COVID-19 pandemic and was only re-launched in August 2023. 

“[Dr Mai] believes at the time they arrived, [the toddler] was alive, from a reversible cause, and he died,” the Coroner’s report found. “Therefore, in her view, this reflects potential inexperience of the road crew and may reflect gaps in airway training skills maintenance.” 

However, the report conceded the toddler was likely already deceased by the time the paramedics arrived, and the outcome wouldn’t have been different even with advanced training. 

The Coroner reiterated that the 11mo’s parents were not at fault for their son’s tragic passing. 

“There is absolutely no evidence that [the boy's] parents were in any way responsible for his passing,” he said. 

“This was a very unfortunate and tragic accident. I convey my sincere condolences to the family and loved ones of [the child].”

Originally published as Tragic accident: Parents not to blame for 11mo who died swallowing metal screw