Ms Beverly Davidge, a 78-year-old woman with intellectual disability living in residential care, died from acute gastrointestinal haemorrhage in hospital. She presented initially with haematemesis and melaena on 11 November 2013, was treated conservatively (deemed unsuitable for surgery), and discharged after 24 hours. She deteriorated at home on 13 November and was readmitted with ongoing blood loss despite transfusions. She became unwell on 15 November, at which point aggressive treatment was ceased in favour of palliation given her comorbidities. The coroner found no evidence of a preventable cause and no relationship between her death and residential care status. Without full post-mortem examination, the precise source of gastrointestinal bleeding remained unidentified.
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