John loved to eat but for the 62-year-old autistic man, food was both pleasure and peril.
He had lived in state care since age eight – including at Kew Cottages, where he survived the 1996 fire that killed nine men. Two decades ago, he moved to a small group home in Ringwood.
John, a 62-year-old autistic man, choked on a piece of banana bread. He was among 38 Victorians – many of them vulnerable – who died from choking in 2024.
There, John found stability and affection. His family, who asked that his surname not be used in this story, knew mealtimes required vigilance because he was a “fast eater”. When they visited and brought fish and chips, they cut his portions with scissors. His carers knew the risk, too: his mealtime plan required food diced into 1.5-centimetre pieces.
In September last year, that system of care failed to save John.
The disability support home where John lived, run by Scope Australia, took residents on a day trip to Healesville.
When bad weather set in, the care staff, including one new to John, decided to stop for a snack onboard their bus. At a service station, John’s carers bought him a coffee and a slice of banana bread.
Inside the parked bus, rain hammering the roof, John grabbed the slice of banana bread before his carer could stop him. It fell to the floor; he snatched it up and put it into his mouth. Within moments, he was choking as staff tried frantically to clear his airway and call for help. By the time paramedics arrived, John had gone limp – the banana bread still lodged in his throat.
Paramedics revived John, but his brain had been starved of oxygen. His sisters, John’s next of kin after their parents’ deaths, were on holiday together in Spain when it happened. Unable to return quickly enough, they said their goodbyes to their brother via a Teams video call as life support was withdrawn.
A Scope spokeswoman said John’s death was “deeply distressing”, but that carers had acted “promptly, appropriately and compassionately”. Scope said it had reviewed the circumstances around John’s death, worked with the coroner and supported attempts to increase awareness around choking risks.
The Victorian coroner ruled the death was not preventable and made no recommendations. Scope said its review also did not identify any systemic failures.
Choking deaths surge in residential care
John’s death was not isolated. Choking-related deaths more than doubled across Victoria’s aged care and disability sectors last year, prompting the state’s health watchdog, Safer Care Victoria, to issue an urgent alert in September.
It warned that choking had become an “emerging quality and safety risk”. John’s was among the choking deaths that formed part of that analysis.
The alert followed a similar national warning from the federal aged care watchdog this June.
There were 17 choking deaths reported to the Victorian coroner in 2023. Last year, that number jumped to 38, according to the Department of Health.
The deaths occurred in public and private facilities alike — in dining rooms, shared homes, and even hospital emergency departments. Common risks, identified in the Safer Care Victoria report, included residents given food or drink inconsistent with care plans, family members unknowingly providing unsafe meals, medications interfering with swallowing, and patients eating unsupervised or sitting incorrectly.
The alert described fatal choking not as a series of freak accidents, but as predictable — the result of thinly stretched staff and poorly followed care plans. It warned that homes must establish “systematic incident review processes” after any choking event or near miss.
While the spike in deaths triggered the new warning in Victoria, there are no nationally available statistics. A University of Technology Sydney review of coronial records nationally shows choking has been a persistent, preventable cause of death in residential care for years.
In January, an NDIS provider was hit with the largest penalty of its kind over the death of an intellectually disabled man who choked on a toasted salami and cheese sandwich.
A known, long-running crisis
Professor Bronwyn Hemsley is head of speech pathology at the University of Technology Sydney. She has spent two decades studying swallowing disorders, known as dysphagia, in people with disability in care. The latest warnings, she said, were all too familiar and should be a catalyst for immediate change.
The same failures repeated year after year, Hemsley said. “With each wave, people recommend similar things to resolve it. Without addressing the systemic issues, these premature deaths continue to rise.”
High staff turnover compounds the danger, with many finding mealtime plans difficult to follow, said Hemsley. In some homes, staff rely on bulky care folders few have time to read. Hemsley said the system needed to be simplified. “A large folder is never going to be read by a new staff member before lunch,” she said. “Carers need real-time support to make sure people have enough time and help to eat safely.”
Hemsley said long delays in speech pathology assessments, and a lack of structured prevention strategies, also compromised safety. “If you go to hospital with a stroke, you’ll see a speech pathologist within 24 hours,” she said. “Some people in care wait weeks or months – all while they’re at risk of choking.”
“The fear, the dread is with me all the time”
For some, the risk of choking is an ever-present part of life. Meredith Allan knows that fear first-hand. The former board member of the National Disability Insurance Agency developed dysphagia after neurosurgery in 1970 left her with an acquired brain injury. And in 2021, surgery to repair a fractured vertebra made eating more difficult.
Meredith Allan at the retirement village where she lives. Allan has severe dysphagia and takes some of her meals via a feeding tube.Credit: Simon Schluter
“My swallowing was stuffed up,” said Allan, whose condition went from moderate to severe dysphagia. In the days after surgery, it took Allan 14 swallows to drink a teaspoon of water.
Doctors offered little explanation. One told her bluntly she would have needed a feeding tube eventually.
Now, Allan eats porridge and soup by mouth but receives her evening meal through a feeding tube – a reality she hates but has built into her life.
She has choked multiple times over the years – on a roast potato, a banana, a small piece of meat. “The fear, the dread is with me all the time. It’s a fragile existence.”
Regulators say risks are known – and preventable
New aged care standards introduced on November 1 include strict food rules, that the federal government envisages moving beyond “meals provided” towards “meals that support dignity, nutrition, health and individual preferences”.
The sector’s watchdog agrees choking remains one of the sector’s most under-recognised risks. Dr Mandy Callary, chief clinical adviser to the Aged Care Quality and Safety Commission, said swallowing difficulties “remain significant clinical risks for older people in aged care, and can lead to serious harm or death if not identified and managed appropriately”.
Aged Care Minister Sam Rae said the government had strengthened standards and boosted funding in the Aged Care Quality and Safety Commission to enforce them.
A texture-modified meal produced by The Pure Food Co. The nutrient-enriched meals are designed to be safer to eat, and to support the health, strength and dignity of people with swallowing difficulties. Credit: The Pure Food Co
A spokesman for Victorian Ageing Minister Ingrid Stitt said Safer Care Victoria issued alerts “to ensure emerging risks are identified early and acted on”.
Feeding the vulnerable, safely
While regulators grapple with prevention, some companies are trying to make safer eating possible.
Among them is The Pure Food Co, which supplies texture-modified meals to more than 500 aged care homes across Australia. Co-chief executive Sam Bridgewater said the mission was personal: his stepfather, who developed jaw cancer 13 years ago, struggled to find safe, nutritious food.
“He couldn’t consume the nutrition he needed or the food he wanted,” Bridgewater said. “It came in little bottles of strawberry-flavoured milk things.”
Roughly 20 to 30 per cent of aged care residents require texture-modified meals, but the results are variable when homes attempt to blend and adapt food themselves.
His company produces purée meals – roast lamb, chicken parmigiana – that seek to look and taste close to the original and are fortified to boost nutrition.
“An absolutely safe texture is critical to mitigate choking risks,” Bridgewater said. “You can’t fix nutrition if someone doesn’t survive the meal.”
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