Deceased
Graziano Birgi
Demographics
86y, male
Coroner
Coroner Dimitra Dubrow
Date of death
2024-10-21
Finding date
2025-11-11
Cause of death
Oesophageal perforation
AI-generated summary
An 86-year-old man with treatment-resistant paranoid schizophrenia residing in a secure psychiatric unit died from oesophageal perforation. He experienced two unwitnessed falls on 20 October 2024 and declined post-fall medical assessment and observations. He had progressive frailty, poor oral intake, and recent palliative care discussions. Post-mortem imaging revealed oesophageal perforation with pleural effusion, likely secondary to underlying disease such as malignancy, chronic ulceration, or inflammation. The death was determined to be from natural causes. Clinical lessons include the importance of thorough post-fall assessment even when patients refuse evaluation, particularly in elderly frail individuals, and consideration of underlying pathology when patients present with declining oral intake and functional status.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
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