Our client, a 74-year-old veteran with significant cognitive and physical impairments, was a resident of a skilled nursing facility. He was known to be at high risk for choking due to a long history of dysphagia and involuntary oral movements caused by medication side effects. One day, he was found in a courtyard unsupervised, with fecal material on his hands, face, and mouth. Despite visible distress, he was not medically assessed at the scene. Critical delays in response and failure to monitor his condition led to a fatal aspiration event. This case settled confidentially for $625,000.00.