Coronial
VIChospital

Finding into death of Mr C

Deceased

Mr C

Demographics

56y, male

Date of death

2022-02-12

Finding date

2023-05-02

Cause of death

Complications of clostridium difficile and malnutrition in the setting of cerebral palsy

AI-generated summary

Mr C was a 56-year-old man with cerebral palsy and acquired brain injury who died from complications of Clostridioides difficile infection and malnutrition. He was admitted to hospital on 21 January 2022 with diarrhoea, elevated inflammatory markers, and abdominal distension following a previous C. difficile infection treated in December 2021. On 23 January, clinicians determined he was not suitable for escalation of care or nasogastric feeding despite refusing oral intake. Palliative care was commenced on 26 January when no improvement occurred. Key clinical lessons include: early recognition that patients with dysphagia and recurrent C. difficile may require proactive nutritional support via nasogastric feeding; consideration of escalation pathways even in complex cases with disability; and ensuring adequate fluid and nutritional intake during acute illness to prevent further deterioration and malnutrition.

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

Contributing factors

  • Recurrent Clostridioides difficile infection
  • Severe malnutrition and weight loss
  • Dysphagia limiting oral intake
  • Refusal of food and fluids
  • Abdominal distension with faecal loading
  • Declining functional status following parental deaths
  • Depression
  • COVID-19 infection in December 2021
  • Recent COVID-19 booster vaccination preceding acute deterioration

Coroner's recommendations

  1. Amend the Coroners Act 2008 to ensure that deaths of NDIS participants in specialist disability accommodation are subject to coronial scrutiny when they occur in care, regardless of whether the cause is natural. The recent amendment to the Coroners Regulations 2019 (effective 11 October 2022) partially addressed this lacuna but consideration should be given to whether the legislative definition in the Act itself requires updating to reflect the shift of disability services funding from DFFH to NDIS.
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