CRITICAL ANALYSIS OF CORONIAL FINDINGS INTO DEATHS FROM CHOKING IN AUSTRALIA

CRITICAL ANALYSIS OF CORONIAL FINDINGS INTO 
DEATHS FROM CHOKING IN AUSTRALIA

In 2024 there are still preventable deaths resulting from choking, particularly in children. These are continuing to happen in homes, schools, and day-care facilities. It can take several years for the responsible State Coroner to get around to conducting an inquest and making recommendations to prevent future deaths. Unfortunately, the outcomes and recommendations of these coronial inquests rarely examine or address the underlying causes of death, but rather tend to treat these events as cases of "bad luck" where recommendations are essentially just to keep doing the same things and hope it doesn't happen again. Very often after these tragic incidents many online "experts" can't wait to tell parents and carers that all they need to do is "have faith in what failed and next time it will work".


"Insanity is doing the same thing over and over again and expecting different results" - Betsy Pickle, not Albert Einstein

The short-sightedness and naivety of this approach are little comfort to the still grieving families and does not address the underlying issues we face in Australia where we are told to rely on poor, ineffective, and unevidenced first-aid recommendations for severe upper airway obstructions and where we are not actively looking for any real solution.

Our mission at LifeVac is to stop preventable deaths from choking; unfortunately most of these cases were. So far LifeVac has saved over 2500 lives, including over 1600 children, all without failure or harm and all after first aid failed. This is not a coincidence! As a result LifeVac has decided to spend some time to review the published Coroner's reports about these cases to critically examine the evidence presented, the validity and rigor of that evidence and the utility and effectiveness of any recommendations made.

Often in these inquest proceedings, the Coroner must rely on expert witnesses, however these can vary greatly in their knowledge and understanding of the evidence and science around choking and choking measures and therefore can adversely influence the understanding and effectiveness of the recommendations made by the Coroner in these cases. Sometimes a formal inquest is not undertaken in favour of a low-level 'investigation' in a Magistrates Court.

This critical analysis will provide the public and authorities with insight into the reasons that these events continue to occur unabated and to make informed decisions in an emergency to prevent a similar outcome. This information is not intended to cause further grief to those who have lost loved ones in such tragic circumstances, but provide insight into how these events can be prevented. In these cases the parents, carers, bystanders and staff acted in good faith in desperately trying to save a life using what they had been trained to do and assured of efficacy and evidence.

Case 1
 
Review of the South Australian Coroner’s Inquest Findings into the death of Lucas Latouche Mazzei
The first case for review was of Lucas Latouche Mazzei who died in 2017 after choking on a nectarine stone in a school classroom in South Australia. The Coroners Report was not released until 2023 and relied heavily on the opinions of an expert medical witness (Professor Anne-Maree Kelly). These opinions were often confused, unfounded and lacked a knowledge of guideline structure, standing and efficacy. The recommendations therefore made by the SA Coroner in this case were at best tokenistic and failed to address the underlying issues that would prevent a reoccurrence of this tragedy. History would bear this out. Read the Coroner's Report and the Critical Review below.

Case 2

Review of the South Australian Coroner's Inquest Findings into the death of Christopher Lens
This case of an unexpected accidental death in a South Australian residential care facility, The Coroner in this case conducted a very superficial inquiry into the circumstances and made no real recommendations or finding that would prevent a reoccurrence. This may have been due to the Mr. Lens' age, mental medical history and situation, however the inquest did not do justice to Mr. Lens or his family in understanding the circumstances and all the contributing factors (weaknesses) in the management of this patient. ​

Case 3

Review of the Record of Investigation into Death (Without Inquest) by the Tasmanian Magistrates Court of Alby Fox Davis
The tragic death of Alby Fox Davis , aged 3 years, 11 months and 22 days, when on Monday 26 February 2018 he choked on a small (50mm) rubber ‘bouncy ball’; and the failure of the Tasmanian Coroner to conduct an inquest into the circumstances, remains one of the worst cases of judicial failure in the unexpected death of a child. The Magistrate in this case made no findings and recommendations and left all the investigation up to the Tasmanian Police to exclude the absence criminal causes. However, in failing to conduct a formal inquest, the failures of the interventions and responses relied upon so heavily; the Magistrate has condemned children like Alby to suffer the same fate. The Magistrate rather deemed the death to be an "unimaginable tragedy" or in other words, just an unfortunate accident, with no solution.