Due to a history of hospitalizations from pneumonia caused by inhaling food, our 83-year-old client was determined at risk for anything but a softened diet. These orders were ignored and she was allowed access to regular food. Several hours after her last meal she began to show signs of breathing problems. When taken to the hospital she was found to have choked on French- fried potatoes. She developed aspiration pneumonia and died ten days later. The case settled through Court mediation in south-eastern Pennsylvania.