Coroner's Finding: CZEKAJLO Helena

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Tanunda and Adelaide in the State of South Australia, on the 13th and 14th days of September, and 7th day of November, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Helena Czekajlo.

I, the said Coroner, do find that Helena Czekajlo, aged 69 years, late of Tanunda Lutheran Home, Bridge Street, Tanunda, died at Tanunda War Memorial Hospital on the 4th day of January, 1999 as a result of respiratory obstruction by aspirated food in a person with schizophrenia and dementia. I find that the circumstances of death were as follows:-

1. Background 1.1 Mrs. Helena Czekajlo was born in Poland on 15 April 1929. According to a “social history” taken at Tanunda Lutheran Home Incorporated (“TLH”), Mrs. Czekajlo came to Australia with her son Jim when she was 37.

1.2 Mrs. Czekajlo appears to have undergone severe emotional trauma when she was still a girl in Poland after Germany invaded in 1939. The casenotes record:- “Most relatives fled the farm where she lived, some went to labour camps. Helena was left with strangers until after the war. Apparently her mental and emotional difficulties stem from this time, and have been labelled “post-war trauma”. She remarried here and lived a very basic (caveman-like existence according to Jim) life in poor conditions”.

(Exhibit C.6c).

1.3 Mrs. Czekajlo lived with Jim until July 1996, when she was admitted to Hillcrest Hospital. She was transferred to TLH in March 1997. The Discharge Summary records her principal diagnosis as “Dementia”, and her psychiatric “problem list”

includes “Chronic Schizophrenia”. Mrs. Czekajlo also suffered from Non-Insulin Dependent Diabetes Mellitus. The Summary records:- “She has a past history of schizophrenia with an admission to Hillcrest in the early 1980’s. It would seem her psychosis has been chronic and she has been on Modecate for many years. It would seem her chronic schizophrenia has modified the clinical picture of dementia. The dementia would seem to be mild or perhaps moderate.

...

Medically she has been stable with her diabetes improving ... with good control of her diet. If not supervised she tends not to keep to her diet. She is now going for a trial in a hostel which is close to her son’s”.

1.4 Mrs. Czekajlo had developed an obsession about food. She could not eat enough.

Her Care Plan, developed in March 1998, records that she “eats hurriedly”, and that she was “very demanding at meal times, comes to the counter to get her meal first”.

1.5 There had never been any suggestion that Mrs. Czekajlo had any difficulty eating.

The only problem recorded is that she needed to be observed as she often failed to comply with her diabetic diet.

2. Events of 3 January 1999 2.1 At lunchtime on that day Ms. Kerry Adams was the carer charged with delivering lunch to the residents. She was alone at the time, since the other carer had gone to lunch. Lunch consisted of “cut up chicken, sliced carrots, sliced beans, about three Brussels sprouts, and mashed potato” (Exhibit C.6, p1).

2.2 A short time after she had given Mrs. Czekajlo her lunch, Ms. Adams heard Mrs.

Czekajlo coughing. She said:- “It was an irritable cough, sort of just like somebody trying to clear their throat”. (T11) 2.3 Mrs. Czekajlo continued to cough and splutter, so Ms. Adams led her to her bedroom.

She indicated that she wanted to go to the toilet, so Ms. Adams facilitated that. While sitting on the toilet, Mrs. Czekajlo continued to cough, so she slapped her on the back, but without result.

2.4 Ms. Adams called for assistance, and was joined by Ms. Lynne Hosking, an enrolled nurse. Ms. Adams stood Mrs. Czekajlo up, and performed the “Heimlich manoeuvre” (standing behind the patient, clasping the hands in front of the chest and pushing the

diaphragm upwards quickly), but this also failed to ease the situation. Ms. Hosking tried slapping her on the back again, and Mrs. Czekajlo vomited. She then showed signs of cyanosis (blue tingeing around the lips), indicating that she was not getting enough oxygen to the lungs.

2.5 Ms. Adams ran to arrange for the suction equipment. She ran to the telephone in the kitchen and called the Registered Nurse in another wing (Ms. Hosking had tried the radio but there was no reply). By the time she got back, Mrs. Czekajlo had stopped breathing. Ms. Hosking said that it seemed as though Mrs. Czekajlo had a “fit” at that stage - she “threw herself back, made a gasping noise, and I couldn’t find a pulse” (T.27). Ms. Adams then ran for the oxygen equipment. When she returned with it, she was unable to use it because:- “Oxygen was escaping from the valve which is between the cylinder and flow meter. I turned it off and tried again and it was still leaking”. (Exhibit C.6, p4).

2.6 Registered Nurse Tracy Maynard, nee Schupelius, arrived and Ms. Adams ran to the wing from which Maynard had come to get the other oxygen cylinder from there. Ms.

Maynard instructed one of the carers to call an ambulance. She attempted suction, but was unable to clear the airway. When the second oxygen bottle arrived, it was found to be empty.

2.7 One of the ambulance officers who attended, Mr. D.P. Schilling, said:- “I dragged her out of the toilet and on to the bedroom floor. I tilted her head back, used a laryngoscope to examine her trachea. I observed a large mass occluding the airway. I then used a magills forcep to remove the foreign body. When I removed the foreign body it appeared to be a mass of cabbage half eaten. Once this was removed I inserted a number 3 laryngeal mask and performed CPR. After a short time (about 10 minutes) I felt a pulse return, however breathing was still absent. I maintained artificial ventilation to her en route to Tanunda Hospital and whilst in the hospital”. (Exhibit C.4a).

I am satisfied, on the evidence, that the food was a Brussels sprout rather than cabbage (see the evidence of Ms. Maynard at T.57).

2.8 On arrival at Tanunda Hospital, Mrs. Czekajlo had good heart function, and her breathing started to become spontaneous. However, irreversible brain damage had occurred, and she remained deeply unconscious. She died at about 1.00a.m. on 4 January 1999. Dr. Martin formally declared her life extinct at 6.55p.m. that afternoon (Exhibit C.2a, p2).

3. Cause of death 3.1 A post mortem examination of the body of the deceased was performed by Dr. R.A.

James, Forensic Pathologist, on 6 January 1999. He found the cause of death was:- “1. Respiratory obstruction by;

2. Aspirated food (brussel sprout, chicken and carrots).

3. Schizophrenia and dementia”. (Exhibit C.3a, p1).

He noted the specimen, referred to by Ms. Maynard, as an “intact Brussels sprout measuring 3.2 x 4cm”. He also noted another intact unchewed Brussels sprout in the stomach, 4cm in diameter, together with other pieces of unchewed food, including a piece of carrot 5cm long (p.2).

3.2 I agree with Ms. H.K. Walters, the Director of Care at TLH, that the likely mechanism of death was:- “You know, I only suspect that what actually happened was she swallowed that brussel sprout which gave her a sore throat because she’d already swallowed one that was bigger than that, whole. And then when she vomited she brought it up and until that time she wasn’t choking at all but after she brought it up then she inhaled it and that’s when the emergency occurred”. (T.50).

4. Issues arising at the inquest 4.1 An overview of the standard of care provided by the TLH was obtained from Ms. J.H.

Ashby, Director of Nursing at the Pines Nursing Home. Ms. Ashby is a highly qualified Nurse and Nurse-Administrator. Her very thorough and well-considered report is Exhibit C.10.

4.2 Eating Ms. Ashby said that, in view of Mrs. Czekajlo’s obsession with food, and her tendency to scoff her food:-

• an assessment by a speech pathologist should have occurred (T.62). (Admittedly, there were no recorded incidents of choking or difficulty swallowing);

• Mrs. Czekajlo should have been toiletted before the meal, so that her anxiety level was low while she was eating (T.63);

• Consideration might also have been given, in consultation with a dietitian, to providing Mrs. Czekajlo with snacks between meals in the hope that this might decrease her tendency to scoff food at meal times (T.66).

4.3 In raising these points, Ms. Ashby acknowledged that Mrs. Czekajlo had “complex care needs”, and she would have been difficult to manage (T.67).

4.4 Ms. Walters said that Mrs. Czekajlo was difficult to take to the toilet, especially at meal times. She also said that snacks were available, although this was not documented in the care plan (T.79). She said that, if Mrs. Czekajlo had demonstrated any problem with swallowing, she would have been assessed by a speech pathologist (T.37). I think that this is a reasonable approach.

4.5 Staffing Ms. Ashby said that, in her view, one person being made responsible for serving food and supervision of eating was an inappropriately low staffing level (T.67). She said that when staffing levels are adequate, routines can be established, and that:- “people with dementia respond very well to set routines and feel secure and their behaviours diminish when that occurs”. (T.68).

Ms. Walters said that there is now a Registered Nurse on duty in the ward where Mrs.

Czekajlo resided (Zerk Ward) for seven hours on Saturdays and Sundays (T.34).

Additionally, a domestic staff person has been assigned to serve meals, so that the carer is left free to supervise the residents (T.38). These are significant improvements.

4.6 Response to emergency Ms. Ashby said that, in her opinion, Mrs. Czekajlo’s initial response in coughing indicated that there was a partial blockage of the airway, perhaps by a bean. Although it was appropriate to try slapping on the back a couple of times, the staff were wrong to persist (T.69).

4.7 Ms Ashby said that, after an initial attempt to clear by slapping, Ms Adams and Ms Hosking should have called a Registered Nurse and organised emergency services as they: “are the only ones that have the equipment and resources to remove anything that’s in the lung or even in the oesophagus”. (T.70).

4.8 Further, when Ms. Hosking tried to dislodge the food, she should have had Mrs.

Czekajlo lying on her side on the floor so that any food that was dislodged would have come out, rather than going down even further (T.71).

4.9 The difficulties the staff encountered with the oxygen equipment were indicative of a lack of appropriate checking and maintenance of the equipment, which should be done daily by the institution of an appropriate system (T.73).

4.10 In this case, the outcome may not have been any better even if the oxygen equipment was working, since Mrs. Czekajlo’s airway was blocked and no oxygen could get past the obstruction (T.80).

4.11 Ms. Walters told me that in her opinion a staff member was at fault, in that the last person to use the oxygen cylinder should have put a sign on it if it was faulty or empty, and the maintenance staff would have attended to it the next day (T.48). She said that this has been reinforced to staff.

4.12 The use of the Heimlich manoeuvre was also questioned. Ms. Ashby said that the Resuscitation Council of Australia recommend lateral chest thrusts with the patient on their side on the floor, so that there is less danger of damage to vital organs (T.74), particularly in the elderly. She acknowledged, however, that opinions vary on the subject (T.80).

4.13 Ms. Walters said that, although the Resuscitation Council published their program in 1995, the St. John Ambulance did not teach that method as part of their senior first aid certificate in 1997 when staff last underwent training (T.39).

4.14 Lateral thrusts are now taught by St. Johns (they did so in a course in 1999) (T.40).

4.15 Ms. Walters was unable to accept the evidence of Ms. Hosking that she was unable to get Mrs. Czekajlo on the floor because she had just returned from major surgery. Ms.

Walters said that she was “able to do her normal duties” (T.40). It seems that there may have been some communication problems in relation to Ms. Hosking’s fitness for work. Perhaps, because lateral thrusts were not used at TLH in January 1999, it was not foreseen that she would need to do so. Hopefully, now that this method is taught, such misunderstandings will not re-occur.

4.16 What is important is that staff receive regular training in choking management and resuscitation so that they can retain their skills, even though such events are rare

(T75).

5. Conclusions

5.1 This incident has highlighted some fairly serious deficiencies in the way the staff at TLH responded to the emergency when Mrs. Czekajlo choked on her food.

5.2 Ms. Walters acknowledged, on behalf of the institution, that they saw the need to review their systems following the incident, and this was attended to promptly.

Systems for checking equipment have been reviewed, staffing has been increased, and staff has been given training on management of choking. Care plans have been reviewed, and the use of a speech pathologist will be extended. She told me that when the TLH was recently accredited, they received a “very good response from the accreditation team on our behavioural management programs” (T.92).

5.3 These have been very thoughtful and conscientious responses to the tragedy of Mrs.

Czekajlo’s death and, although nothing can be guaranteed, these actions should ensure that a similar incident is less likely to occur. Accordingly, I will make no recommendations pursuant to Section 25(2) of the Coroners Act.

Key Words: Aged Care; Asphyxia; Dementia; Institutional Death; Nursing Home In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of November, 2000.

……………………………..……… Coroner Inq.No38/2000