Finding into death of Stephen David Johnston
Deceased
Stephen David Johnstone
Demographics
64y, male
Date of death
2020-12-09
Finding date
2022-02-28
Cause of death
Aspiration pneumonia with cerebral palsy as a contributing factor
AI-generated summary
A 64-year-old man with cerebral palsy, intellectual disability, dysphagia, and recurrent respiratory infections died of aspiration pneumonia. He was receiving disability support services through Melba Support Services. In the weeks before death, he experienced vomiting, hiccups, and lethargy, was seen by locum doctors and his GP, then admitted to hospital where palliative care was initiated. The Disability Services Commissioner investigated and identified that staff had not received formal training in his mealtime assistance plan, a falls risk review was incomplete, and mealtime support was not consistently compliant with his plan. These issues were addressed through an amended action plan. No adverse findings were made against any clinician or service provider.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- cerebral palsy
- dysphagia
- recurrent respiratory infections
- inadequate formal training of disability support staff in mealtime assistance plan
- inconsistent implementation of mealtime support plan
Full text
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