Graeme William Kenny, a 61-year-old man with trisomy 21 and dementia, died from right lower lobe pneumonia on 25 December 2024 at Monash Medical Centre following palliative care. He developed upper respiratory symptoms on 3 December 2024, treated initially as upper respiratory tract infection with oral antibiotics by his GP. Despite ongoing productive cough, lethargy, and gurgling breathing, clinical deterioration was not recognised until 22 December when he presented to ED with sepsis. The coroner found no want of clinical management or care by any involved healthcare providers. For clinicians: recognise that residents with intellectual disability and dementia in supported accommodation may have atypical presentations of serious infection; maintain high vigilance for chest infection progression in this population despite apparently stable vitals; consider earlier escalation and imaging (chest X-ray) when productive cough persists despite antibiotics.
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