Joan Pauline Skillen, a 93-year-old woman with intellectual disability residing in specialist disability accommodation, died from pneumonia. She had dysphagia and multiple comorbidities. Initial symptoms (milky discharge, wet-sounding breathing) were noted in August 2024 and reviewed by her GP, who recommended monitoring. In September, she developed a chest infection requiring hospitalisation and antibiotics. She was discharged with palliative care referral. Despite appropriate clinical management including antimicrobial therapy and palliative care involvement, her condition deteriorated and she died peacefully at home. The coroner found no deficiency in clinical care or disability support provision that contributed to her death, which was from natural causes.
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