Gary Carrick, a 45-year-old man with Down syndrome and severe progressive cervical myelopathy, died from bronchopneumonia. He experienced rapid functional decline from January 2008, including loss of mobility, incontinence, and development of infected pressure ulcers. An MRI in May 2008 confirmed severe cervical myelopathy unsuitable for surgery. Management focused on conservative care and pressure ulcer treatment. He was admitted to hospital on 9 June 2008 with worsening infected ulcers and transferred to palliative care on 11 June, dying 5 days later. The Clinical Liaison Service review found medical management reasonable, though earlier inpatient investigation might have expedited diagnosis without changing management. The coroner acknowledged DHS could have provided higher-level care earlier but found no grounds for formal recommendations, noting appropriate responses to family concerns.
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