An aged care facility in Sydney’s inner west has been accused of staging a “cover-up” after the choking deaths of two patients within nine months, an inquest has heard.
Dimosthenis Gesios and Maureen McGreevy were both residents at the Acacia Centre in Marrickville when they died after being given bread.
Both patients had been prescribed a “minced and moist diet” and were medically restricted from eating bread.
Mr Gesios died in June 2019, while Ms McGreevy died in March 2020.
The facility, owned by Columbia Aged Care, was closed in 2022 before hearings into the inquest were held in August 2023.
Columbia runs three other facilities in Strathfield, Oberon and Chatswood.
The inquest heard how their deaths were referred to the Coroner after an anonymous complaint was made to the Aged Care Quality and Safety Commission alleging “a cover-up” of the circumstances surrounding Mr Gesios’ death.
The beloved grandfather’s cause of death was originally recorded as “a seizure while being fed”.
The inquest found registered nurse Nagendra Koirala and Facility Services Manager Dr Irene Stein deliberately omitted any mention of Mr Gesios choking on bread from the official incident report.
In response to news.com.au reaching out to Mr Koirala, he said: “No comment”. Dr Stein did not respond to multiple requests for comment.
Both have been referred to the NSW Executive Officer of the Nursing and Midwifery Council as a result.
The inquest heard how on June 7 at about 7.30am, Nurse Koirala went to Mr Gesios’ room and gave him his medications before breakfast.
About 8am, an assistant in nursing collected his breakfast tray, which included bread, a cup of Milo, porridge and scrambled eggs.
The assistant in nursing began feeding Mr Gesios the bread – which was being dipped into the Milo – when he began choking.
Nurse Koirala obtained a suction machine to remove the food to no avail.
Paramedics arrived at the facility and pronounced him dead.
The inquest heard the assistant in nursing did not have “sufficient understanding and use of English” and “did not have a good understanding” of how to feed someone with swallowing problems.
“The manner in which Mr Gesios was fed was unsafe and not appropriate for his needs,” the inquest heard.
“The person responsible for feeding Mr Gesios, did not know his medical background or appreciate his requirement for the small particle sizes of a Minced and Moist diet.”
Incident report of Mr Gesios’ death
The incident report written about four hours after Mr Gesios’ death by Nurse Koirala and Dr Stein stated the patient had a “seizure” during breakfast.
“Whilst being assisted one-to-one with breakfast Mr Demosthenis [sic] had a seizure, eyes rolled back in his head and he was twitching,” the incident report said.
“He coughed out last mouthful of food he had been offered”.
Nurse Koirala also failed to mention the bread in a police statement in October.
“In his oral evidence during the inquests, RN Koirala provided several different reasons why the Incident Report omitted any mention of Mr Gesios being fed bread and choking,” Deputy State Coroner Magistrate Derek Lee said in his findings.
“The reasons provided by RN Koirala were inconsistent and none of the reasons were persuasive.”
The inquest heard that in a statement made in 2020, Nurse Koirala eventually admitted he should have told the police “the entire truth”.
In her oral evidence, Dr Stein denied omitting any reference to choking in the Incident Report “in order to avoid attention to the Acacia Centre”.
However, when asked why there was no reference to choking in the Incident Report, Dr Stein said she had “no idea” and noted that she was new to the organisation at the time.
“The evidence therefore establishes that Dr Stein, with adequate information available to her, omitted to correct factual aspects of the Incident Report and omitted relevant factual information,” Magistrate Lee found.
Magistrate Lee said there were “reasonable grounds” that a complaint could be made about the professional conduct of Dr Stein and Nurse Koirala.
Nurse Koirala is now the Care Manager at Bankstown City Aged Care, while Dr Stein works as a specialist at aged care consulting service Anchor Excellence.
Maureen McGreevy’s death
Nine months later, Ms McGreevy, who was also supposed to be on a minced and moist diet, was delivered a meal tray with half a slice of buttered bread on March 13 at about 5pm.
Around 7pm, Ms McGreevy was seen by a staff member having trouble breathing.
Paramedics were called to the facility and found Ms McGreevy had a “complete airway obstruction”.
A lump of bread was removed from Ms McGreevy’s airway, but she could not be revived.
An autopsy found her death was caused by choking.
The inquest found Ms McGreevy was given another patient’s meal tray.
Columbia Aged Care told the inquiry that there were “inconsistencies” in terminology used by staff and in policy documents regarding the type of diet that a resident may be prescribed.
The organisation said it had since implemented mandatory online training for choking and swallowing difficulties for all staff.
It also noted to the inquiry it had since closed the centre, but said it was due to the fact the facility was “no longer fit for purpose” due to the “age and configuration of the buildings”.
Magistrate Lee recommended that the International Dysphagia Diet Standardisation Initiative Board review and clarify the minced and moist diet.
A spokeswoman for the Nursing and Midwifery Council of NSW told news.com.au they would be working alongside the NSW Health Care Complaints Commission to “manage” the findings about Nurse Koirala and Dr Stein.
“We focus on safe professional practice, maintaining public safety and minimising risk,” she said.
“We act to prevent unsafe practice and have legal powers to enable us to do so.”
In a statement to news.com.au, Columbia chief executive officer Nick Moutos said the company “deeply regrets” to deaths of Mr Gesios and Ms McGreevy.
“We sincerely apologise and acknowledge the immense impact these have had on their families. Since the deaths in 2019 and 2020, the Acacia Centre has closed.
“Columbia remains committed to the continuous refinement of its policies, procedures and staff training to guarantee the highest standard of best practice within our facilities.
“Columbia will continue to reflect on the Coroner’s findings and we thank the Coroner for a thorough investigation.”
Get in touch with our reporter. Sarah.Keoghan@news.com.au
