NSW Coroner makes findings on aged care choking deaths
The NSW Coroner has examined the deaths of two aged care residents who died by choking within nine months of each other at the same aged care home.
Dimosthenis Gesios and Maureen McGreevy were both residents at the Acacia Centre aged care facility, in Marrickville, 7km southwest of the Sydney CBD, when they died. Dimosthenis died in June 2019, while Maureen passed away in March 2020.
Acacia Centre was owned by Columbia Aged Care. The home closed in 2022.
Hearings for the inquiry were held in August 2023, and then again in February 2026. Deputy State Coroner Magistrate Derek Lee handed down his findings on 27 February 2026.
An inquiry into the two deaths was combined because common issues were identified. Both residents had been prescribed a ‘minced and moist’ diet, which was supposed to restrict what they could and could not eat – and both died after consuming bread.
The Coroner made two recommendations.
- The findings be provided to the Aged Care Quality and Safety Commission for them to consider if consistent minimum training requirements should be introduced for kitchen and nursing staff working in aged care, specifically directed at the identification and management of choking risk.
- That the finding be provided to the Board of the International Dysphagia Diet Standardisation Initiative to consider if gelled bread should be removed as a permissible food as part of a ‘minced and moist’ diet or if gelled bread and its preparation be better defined and described.
Columbia Aged Care CEO Nick Moutos, who only commenced as CEO at the start of this year, told the inquiry that he will raise the issues with his clinical governance manager and ensure the matter is “taken seriously”.
