Brian Maher, a 44-year-old man with Down syndrome, died from bilateral pneumonia following rapid clinical deterioration. He presented to hospital on 2 December 2017 with dyspnoea and was admitted to the emergency department at Ballarat Hospital. Despite initial care, his condition deteriorated and he was transitioned to palliative care on 3 December, dying on 10 December 2017. The coroner found that care provided by both the Department of Health and Human Services and Ballarat Health Services was reasonable and appropriate. No clinical errors or preventable factors were identified. The death was determined to be from natural causes.
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