Child that choked on plastic glove 'shouldn’t have died'
All disabled children living in institutions or respite facilities should have a dedicated "key worker" responsible for overseeing their care, the Deputy State Coroner has recommended.
The recommendation comes as part of inquest findings into the death of Sophia Nisco who died at age 16 in a respite care centre after choking on a plastic glove.
Deputy Coroner Anthony Schapel concluded that Sophia's death would have been prevented if she had been given appropriate supervision by staff at disAbility Living Riverside respite facility.
Sophia suffered from a range of disabilities including cerebral palsy and an intellectual disability.
She had problems swallowing and had a gastronomy tube in her abdomen for fluids and medication to be fed directly to her stomach.
A specialist paediatrician told the Coroner's Court that Sophia had a functioning mental level of an infant less than 12 months old.
She was not able to communicate in words and crawled, instead of walking.
Sophia's mother Nella Nisco provided extensive care to her daughter and held off accessing respite care for many years.
Sophia was in the facility for one weekend every fortnight.
On February 11, 2017, Sophia was in the playroom at the facility, which houses four children, when one of the other residents started banging his head.
As the two staff members responded to the boy in another room Sophia crawled to the bathroom and put a plastic glove in her mouth.
Staff returned to the room to find Sophia missing and started to search the nearby rooms.
They found her in the bathroom with not breathing and with no pulse. They started CPR but had not noticed the glove stuck in her throat.
During six days of hearings in the Coroner's Court, Mr Schapel heard extensive evidence that staff were aware that Sophia often put things in her mouth and was at risk of choking.
The concerns of Mrs Nisco and her partner were raised with staff only weeks before Sophia died.
"To my mind the number of carers present at the premises at the time of the fatal incident was manifestly insufficient," Mr Schapel said.
"Her death would have been prevented if she had been provided with the necessary level of supervision and observation."
He commended disAbility Living for implementing a series of measures designed to prevent choking at the facility.
However, he also made further recommendations including carers having access to the medical records of disabled children in their care and improved care plans.
"The Court recommends that in respect of the care of disabled children in institutions and respite facilities that a dedicated 'key worker' be assigned to each individual child," he said.
"The key worker should be responsible for the oversight of the care provided to the child, for the education of other care workers in respect of the needs and safety of the child."