Bridie Gilligan, 42

Bridie, 42, had profound intellectual disability, Cornelia de Lange syndrome and dysphagia (swallowing difficulty). She choked on food at her supported independent living (SIL) home, and subsequently died from hypoxic brain injury.

The coroner did not blame the support worker’s supervision that afternoon, and found that earlier removal of the obstruction by paramedics was unlikely to have changed the outcome. But the inquest exposed broader failures: an incomplete dysphagia assessment, poorly communicated mealtime guidance, and separation between SIL, allied health and support coordination. Recommendations to the NDIA and the NDIS Quality and Safeguards Commission included communication protocols, funding for complex case management, guidance for when health recommendations conflict with participant choice, and funding for allied health professionals to train SIL providers.