Deceased
Chris Perdios
Demographics
42y, male
Coroner
Coroner Simon McGregor
Date of death
2018-10-15
Finding date
2020-05-25
Cause of death
Aspiration pneumonia in the setting of impacted large bowel in a man with intellectual disability and chronic constipation
AI-generated summary
Chris Perdios, a 42-year-old man with intellectual disability, autism, and chronic constipation, died from aspiration pneumonia complicated by an impacted large bowel. He was admitted to hospital on 12 October 2018 with acute pancreatitis and bowel obstruction, treated in ICU with sedation and intubation, then self-extubated on 14 October. Despite appearing stable on 15 October, he deteriorated acutely and died at 8:15pm. The Disability Services Commissioner identified systemic deficiencies in disability support provider Yooralla's care: lack of integrated health management plan, inadequate communication tools for non-verbal patients, and poor coordination between care home and hospital staff. These included absent monitoring of nutrition/constipation, undocumented speech pathology recommendations regarding aspiration precautions, and delayed medication reinstatement. While these gaps did not directly cause death, they impacted his comfort and dignity. Yooralla subsequently implemented comprehensive improvements including DisDat assessment tools, consolidated health plans, and health passport systems for hospital admissions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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74y · Male·Acute myocardial infarction complicated by multiple organ failure
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