A teenager with disabilities who choked on a latex glove while in respite care in Adelaide would not have died if she was properly supervised, a coroner says.
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Sophia Nisco, who had cerebral palsy and other health issues, died in 2017 at the disAbility Living's Riverside facility.
The 16-year-old, who had a fixation with putting things in her mouth, choked on the glove and was in cardiac arrest and unresponsive when paramedics arrived.
In his findings on Friday, deputy coroner Anthony Schapel said the girl had not been provided with the appropriate level of supervision despite management and staff knowing of her habit to put things in her mouth.
He said the number of staff at the care facility was also inadequate at the time of her death.
"Sophia required constant observation while on the Riverside premises. She did not receive constant observation," Mr Schapel said.
"It was while she was unobserved that she was able to find a glove and aspirate it.
"Her death would have been prevented if she had been provided with the necessary level of supervision and observation."
In his recommendations, the deputy coroner called on disAbility Living to revise its procedures in relation to care plans for individual clients, with emphasis on the risks posed by any particular behaviours.
He said staff in such facilities should also have access to a patient's medical history and urged the appointment of "key workers" to take charge of the care of each child.
During the inquest, Vince Nisco said his daughter had been attending the respite home regularly for about two years and for the most part the care provided had been good.
Mr Nisco said he hoped the inquest would lead to staff being given clearer instructions on the care required for some high-needs children.
"Unfortunately it doesn't look like there was clarity in how to perform their jobs for certain clients," he said.
Australian Associated Press
