David Stanley Ayres, aged 65, died from sepsis due to aspiration pneumonia while in hospital detention under a Mental Health Act order. He presented to his GP on 8 June 2011 with suspected urinary tract infection and was prescribed cephalexin. Documentation at the residential facility showed only 5 of approximately 20 expected antibiotic doses were recorded, though inventory suggested medication was likely administered but poorly documented. He was admitted to hospital on 14 June with community-acquired pneumonia, initially improved in ICU, but developed hospital-acquired pneumonia on the ward. He deteriorated despite appropriate treatment and died from aspiration pneumonia. The coroner found appropriate treatment throughout and made no recommendations, though documentation gaps at the residential facility were noted.
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