A care provider gave inadequate supervision to a woman who choked on food and died, a coroner has found.
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Joanne Avis Callahan, 43, lived in a group home operated by the Department of Health and Human Services on Last Street in Beechworth.
The 43-year-old had autism and an intellectual disability, and could only communicate in short sentences.
Ms Callahan arrived at the Yarrunga Community Hub in Wangaratta at 9am on November 1, 2018, for activities.
The program was undertaken by Gateway Health staff, with four workers supervising her group at the time.
Ms Callahan was sitting at a table about 11.45am and was eating a sandwich when a worker saw her stand up and walk to the toilet.
The disability worker noticed her lips were blue and she was making a "squeaky" sound.
Another client said she had something in her mouth and the worker followed Ms Callahan.
The worker told her to cough out the food and sought help from another employee.
The 43-year-old made a wheezing sound and was thrust on the back but went limp a short time later and her legs gave way, with staff putting her in a recovery position.
The food remained stuck as staff tried to blow air into a face mask, with paramedics arriving and noting her airway was completely obstructed.
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She was unconscious with no heartbeat and died in hospital at 2.43pm.
The late woman's sister, Sharon Dellora, wrote to the coroner to raise concerns about the care given to Ms Callahan on the day, including the staff-client ratio.
Concerns were also raised about supervision and the apparent lack of awareness by Gateway Health staff about Ms Callahan's needs.
The Disability Services Commissioner found the late woman wasn't adequately supervised during meals, staff failed to recognise choking signs and Gateway Health did not seek information about the mealtime support she required.
DHHS staff also failed to give essential information to the service provider and administered chemical restraints, in breach of the law.
Record keeping shortcomings were also found.
Coroner Katherine Lorenz found Ms Callahan's supervision was inadequate, DHHS failed to provide information about her choking risk to Gateway Health, and that changes would address the inadequacies in the provider's supervision and rostering.
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