Donald Walter Thoms, 90 years old with intellectual disability and high aspiration risk, died from complications following aspiration of food while in specialist disability residential care. He was on a pureed diet and thickened drinks with close monitoring during meals. Following an ED presentation two days prior for suspected aspiration, he was managed palliatively at his care facility. Support staff appropriately recognised swallowing difficulty, ceased fluid administration, and maintained observation. The Health and Medical Investigations Team found no concerns with care provided by Life Without Barriers or Calvary Bethlehem Palliative Care. The decision to provide oral nutrition despite aspiration risk is standard practice when a meal management plan exists and family are informed. Death was determined to be from natural causes with no causal connection to his 'in care' status.
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