The Coroner’s Court of Victoria has handed down a finding into the death of a man in specialist disability care who choked while on an outing in Healesville.
62-year-old John Jurdeczka had lived under 24 hour car in a specialist disability home in Ringwood, staffed by Scope Australia since 2019, and died while in the intensive care unit at the Angliss Hospital in Upper Ferntree Gully on 28 September 2024.
John had autism, an intellectual disability and various chronic medical problems that had been stable in the six months prior to his death, including dysphagia (difficulty swallowing).
John had a Mealtime Management Plan, which outlined his ability to chew soft/tender foods without help, no swallowing problems and no increased risk of choking, but also include risk reduction strategies like close supervision at meal times, verbal prompts to eat slowly and cutting up his food into bite-sized pieces.
On 25 September 2024, two qualified casual Scope Support Workers, Baljit Singh Kanwar and Koshy Panicker took John and two other residents at the Ringwood facility on a day trip to the Maroondah Reservoir Park. Koshy had only worked two to hree shifts supporting John and Baljit none prior to this day, though both had reviewed his support plans.
Koshy said they were aware John could move quickly and often had to be told to stop or slow down, including when eating while Baljit said they ahd been told by other workers tat John had an obsession with food, tending to grab at it and eat quickly, sometime without chewing.
On the day, they arrived in Healesville to heavy rain and wind so chose not to leave the bus and instead went to the Shell petrol station to buy some food for John and the other residents.
Koshy purchased some banana bread and coffee and while they normally ate outside, chose to eat on the bus due to time restraints and the weather, which is not unusual or inappropriate.
Baljit opened up the banana bread and John grabbed it quickly, Baljit slapped it out of his hand and it dropped to the floor before John grabbed it and put it straight into his mouth.
Both Baljit and Koshy then tried to remove the banana bread from John’s mouth which proved difficult as he was in a difficult position and was flailing his arms and pushing them away.
As John attempted to swallow, the banana bread became lodged in his throat so Balhit called Triple Zero to request an ambulance, while having to ask the service station attendant for the address and if they had a defibrillator. Koshy attempted back blows to John to try and dislodge the banana bread but had difficulty due to the positioning on the bus and was unsuccessful.
At the advice of the emergency call taker, Koshy, Baljit and the attendant removed John from the bus, despite some difficulty due to the wet floor from rain and spilled coffee.
Koshy and Baljit were about to commence CPR when an ambulance crew arrived and took over, about two to three minutes after the emergency call, and the Ringwood facility supervisor also came to the scene while emergency services worked to bring John’s client file.
John was first transported to the Box Hill Hospital emergency department and later to the intensive care unit at the Angliss, where a CT scan showed the first signs of brain injury from the incident. Two days later, John underwent brain stem testing which declared him clinically brain dead.
John’s two sisters, who were his next of kin, had been contacted on the day of the incident while on holiday in Spain, and asked after the news of John’s brain death if the hospital could wait until they returned on 30 September to be with John as he died, but were informed of the risk of cardiac arrest the longer they waited. On 28 September, his sisters were present via video link as John’s ventilator was removed and he died.
Coroner Simon McGregor found that John’s death was not preventable and that his care was reasonable and appropriate.
