Health officials in Quebec confirmed Monday they are revisiting the place of the grilled cheese sandwich on menus in care facilities following the choking deaths of at least two elderly residents in recent years.
A coroner concluded earlier this year that the sandwich appears to pose a particular choking risk to the elderly after two residents of the same St-Jean-sur-Richelieu, Que., care home died in similar circumstances, three years apart.
Coroner Andre-H. Dandavino recommended that both the local health authority and the provincial Health Department review the risks associated with grilled cheese sandwiches following the deaths of Clemence Thibodeau in 2015 and Monique Leboeuf in 2012.
"The grilled cheese sandwich seems to be problematic and risky for the elderly," he wrote in his report.
Thibodeau, who was 78, died in hospital the day after getting part of a sandwich stuck in her throat at the care home where she lived, the report said.
The woman, who suffered from a long list of health problems including Alzheimer's disease, Parkinson's disease, as well as heart, kidney and breathing problems, had been previously evaluated and deemed able to swallow textured foods and eat on her own as long as she was supervised and the meal was cut up.
Leboeuf, for her part, began coughing and choking after eating a grilled cheese sandwich in Dec. 2012 and later stopped breathing, even though the obstruction was cleared.
Dandavino ruled it was "a violent death by asphyxia from a foreign body."
Martine Lesage, a spokeswoman for the regional health authority, said it has since removed grilled cheese from the menu for residents who are on a soft food diet, because "it can form a ball in the mouth that can be more difficult to swallow."
She said the province's health department is also finalizing a wider action plan to minimize choking risks that includes information about the risks of sandwiches, including grilled cheese, and more staff training on general food and choking safety and best practices.
But she said the residences also take people's preferences into account, and will work with residents to make it safe for them to eat their favourite foods even if they aren't on an approved list.
Lesage said she couldn't provide numbers on how many choking deaths have occurred in the regional's facilities in recent years, but said the last fatality was in 2016.
Nalini Sen, the research program director at the Alzheimer Society of Canada, said people experiencing dementia can be especially prone to choking as the brain loses the ability to direct the body to chew and swallow.
She said that certain foods, including grilled or toasted breads, can be harder to swallow, but that simply banning certain foods isn't the solution to mealtime challenges.
Rather, she advocates a more "person-centred approach" that includes paying attention to the mealtime environment, how food is prepared and presented and the person's overall oral health.
"Do they have a dry mouth, do they have dentures that fit properly, are their teeth worn or missing?" she said in a phone interview. "These things can impact their ability to properly chew, swallow or consume their food."
She said sometimes giving water, or cutting food into smaller pieces, can make it easier to chew and swallow, while keeping presentation simple and having a helpful but respectful attitude can reduce mealtime anxiety, which can be a factor in choking.
In an email, the Quebec Health Department confirmed it was heeding the coroner's recommendations and is finishing a comprehensive review of the risks of choking on food in the province's network of facilities.
But it said grilled cheese in particular wasn't a target.
"Although Coroner Dandavino's report targets the risk associated with the grilled cheese sandwich that is involved in this particular death, the (Health Department) is focusing its thinking more on the measures to be put in place to reduce the risk of choking in general," Noemie Vanheuverzwijn wrote.
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