Tamara Kudeviita, a 59-year-old woman with Down's syndrome and advanced Alzheimer's disease, died of pneumonia in a palliative care unit. She had been declining throughout 2022, with loss of swallowing ability, mobility, and communication. She was appropriately referred to palliative care in March 2022 and admitted for end-of-life care in December 2022 when unable to swallow. She received appropriate comfort care including subcutaneous midazolam for seizure management and morphine for breathlessness. The coroner found no preventable factors and determined her death was due to natural causes with no causal connection to her status in disability accommodation care.
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