A 59-year-old man with severe acquired brain injury and dysphagia from a 2005 motorcycle crash died from aspiration pneumonia. Two days after returning from a UK holiday, he fell in a bathroom at his group home. He was found in cardiac arrest and transported to hospital where he died that evening. Autopsy revealed aspiration pneumonia with no significant head injury despite the fall. Alcohol consumption on the day of death likely contributed to the fall, but the death resulted from aspiration due to his pre-existing swallowing difficulties. The coroner found no deficiency in care provided by the group home, ambulance service, or hospital. Clinical lessons include recognizing aspiration risk in patients with dysphagia, particularly when alcohol may impair protective reflexes.
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