Paul Joseph Milward

Paul had Huntington’s disease and a known choking risk. He died after being left alone with food, contrary to his care requirements.

The coroner explicitly recommended that choking deaths of people with disability in care be recognised as a systemic issue and incorporated into the NDIS quality assurance and reporting framework. Other recommendations addressed care plan handover, routine reviews, and medical monitoring for dysphagia. This case is useful historically because coroners were warning about precisely the kinds of swallowing and mealtime risks seen again in later NDIS cases, such as Bridie Gilligan’s.