Diane Young, a 72-year-old psychiatric resident with multiple comorbidities including asthma, aortic stenosis, and intellectual disability, died of bronchopneumonia with contributing ischaemic heart disease. She was seen by her geriatrician two days before death and found well with only lymphoedema noted. She had vomited the evening before death while drinking water—a known issue given her tendency to eat quickly without chewing and excessive fluid intake for which she had been referred for swallowing reassessment. She was found unresponsive at 6:15am and died shortly after. The coroner found no evidence of medical error or preventable delay. Clinical lessons include the importance of swallowing assessment implementation in patients with dysphagia risk factors and rapid response to signs of acute illness in vulnerable elderly residents.
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