Coronial
VIChospital

Finding into death of Clifford Norrie Wall

Deceased

Clifford Norrie Wall

Demographics

79y, male

Date of death

2016-06-18

Finding date

2017-06-27

Cause of death

Aspiration pneumonia in the setting of small bowel obstruction

AI-generated summary

A 79-year-old man with intellectual disability and multiple comorbidities (atrial fibrillation, COPD, epilepsy) presented with vomiting on 9 June 2016. His GP was initially not concerned, but after a third vomiting episode, small bowel obstruction was suspected and he was transported to hospital. CT confirmed obstruction; he was deemed unsuitable for surgery due to comorbidities. Aspiration pneumonia developed with worsening respiratory failure despite antibiotics. He was transitioned to palliative care and died 18 June 2016. The coroner found no causal relationship between his death and his status as a person in care, and found care provision reasonable and appropriate. Clinical lessons: early recognition of aspiration risk in patients with bowel obstruction and neurological impairment; careful weighing of surgical risks in elderly patients with multiple comorbidities.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • small bowel obstruction
  • intellectual disability affecting communication and swallowing safety
  • multiple comorbidities including COPD and atrial fibrillation
  • surgical ineligibility due to comorbid disease burden
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