Deceased
Michael Manuel Luno
Demographics
66y, male
Coroner
Coroner Sarah Gebert
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. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
38y · Female·Multiple injuries sustained when struck by a train
Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.