Inquest into the deaths of Dimosthenis Gesios and Maureen McGreevy

Case Number: 2019/00184731; 2020/00083104

Date of Findings: 27 February 2026

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW – cause and manner of death, dysphagia risk, choking risk, residential aged care facility, chewing and swallowing, International Dysphagia Diet Standardisation Initiative, minced and moist diet, speech pathology, gelled bread, incident reporting, Aged Care Quality and Safety Commission, Health Practitioner Regulation National Law (NSW)

Responses

Recommendations

To the Aged Care Quality and Safety Commission:

1. I recommend that a copy of the findings from the Inquests into the deaths of Dimosthenis Gesios and Maureen McGreevy be provided to the Aged Care Quality and Safety Commission for consideration.
   It is recommended that the Commission consider developing consistent minimum training expectations for kitchen and nursing staff in residential aged care facilities, specifically directed to the identification and management of choking risk among residents, including alignment with the International Dysphagia Diet Standardisation Initiative Framework.
   In developing this guidance, it is also recommended that the Commission consider including a structured approach to assist aged care providers to:
   (a) assess and document the competency of nursing staff, particularly Assistants-in-Nursing, in recognising and managing choking risk; and
   (b) implement periodic review or quality assurance processes to promote consistency and ongoing effectiveness.

To the Board of the International Dysphagia Diet Standardisation Initiative:

1. I recommend that a copy of the findings from the Inquests into the deaths of Dimosthenis Gesios and Maureen McGreevy be provided to the Board of the International Dysphagia Diet Standardisation Initiative for consideration of whether
   (a) gelled bread ought to be removed as a permissible food as part of a minced and moist diet; or
   (b) gelled bread, and its preparation, ought to be more well defined and described.