Finding into death of Barry Robert Johnson
Deceased
Barry Robert Johnson
Demographics
68y, male
Date of death
2022-05-31
Finding date
2024-10-17
Cause of death
Metastatic colorectal carcinoma
AI-generated summary
Barry Johnson, a 68-year-old man with intellectual disability, autism, cerebral palsy and dysphagia, died from metastatic colorectal carcinoma at his specialist disability accommodation home. He had been diagnosed with ascending colon adenocarcinoma in March 2020 and was not for active treatment. In May 2022, he showed signs of decline with low haemoglobin and elevated inflammatory markers. On 27 May, his GP reviewed blood tests and commenced antibiotics. That evening he developed fever and appeared unwell; paramedics were called but did not attend due to reported delays. He remained stable overnight. On 30 May his GP prescribed constipation treatment and recommended urgent EPCT review. He died suddenly on 31 May. The coroner found no relationship between the cause of death and the care received. The case highlighted the need for enhanced oversight of vulnerable SDA residents, leading to regulatory amendments.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Contributing factors
- Advanced metastatic colorectal cancer
- Perforated bowel identified on post-mortem imaging
- Declining health in final weeks with fever, elevated inflammatory markers, and anaemia
Coroner's recommendations
- Enhanced oversight and investigative processes for Specialist Disability Accommodation residents, now codified in amended Coroners Regulations 2019 effective 11 October 2022
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