A Court of Claims case against a New York state facility for developmentally disabled adults. While staff were supposed to be monitoring her, but were not, the deceased, who was a Down's Syndrome patient, choked on a breakfast item, asphyxiated, and died after months of intensive care in the hospital.
Whereas the attorneys for the State maintained it was the family's responsibility to inform the facility of her particular risk of choking, staff at the facility failed to follow the patient's dietary plan, as ordered by the facility's own physician, who also failed to do a simple 'swallow test' on the patient when she joined the facility. The facility's own in-house physician admitted this at his deposition.