Robert Djurovich, a 58-year-old man with Down syndrome, dementia, epilepsy, and gastro-oesophageal reflux disease, died from aspiration pneumonia on 1 January 2023 after admission to Maroondah Hospital on 1 November 2022 following an aspiration event. He had been a long-term resident of a Specialist Disability Accommodation facility and was an NDIS participant. His health had been declining for six years due to progressive dementia. The coroner found no evidence of want of clinical management or care by the SIL provider or hospital staff that caused or contributed to his death. The death was determined to be from natural causes. Clinically, this case underscores the heightened aspiration risk in individuals with intellectual disability and dementia, and the importance of multidisciplinary swallowing assessment and management strategies in this vulnerable population.
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