Finding into death of Michael Manuel Luno
Deceased
Michael Manuel Luno
Demographics
66y, male
Date of death
2023-05-13
Finding date
2024-01-11
Cause of death
Aspiration pneumonia in the setting of a small bowel obstruction
AI-generated summary
Michael Luno, a 66-year-old man with intellectual disability, autism, epilepsy, and swallowing difficulties, died from aspiration pneumonia complicating small bowel obstruction. He presented with vomiting and abdominal distention on 8 May 2023. At hospital, he developed projectile faeculent vomiting after nasogastric tube insertion, with subsequent aspiration. A Code Blue was called despite his documented 'not for resuscitation' status because this had not been formally entered into the hospital system. He was intubated and admitted to ICU but did not recover meaningful function. The case highlights the importance of immediately documenting advance care directives in hospital systems to prevent unintended resuscitation, and ensuring that patients with swallowing difficulties and bowel obstruction receive appropriate monitoring and care planning.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Small bowel obstruction
- Swallowing difficulty
- Nasogastric tube insertion triggering projectile vomiting
- Delay in formal documentation of 'not for resuscitation' status in hospital system
- Aspiration of gastric contents
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