Finding into death of PSD

AI-generated summary

A 66-year-old woman with cerebral palsy, dysphagia, and chronic reflux oesophagitis presented with acute gastrointestinal bleeding while in supported disability accommodation. She was treated conservatively with IV proton pump inhibitors rather than gastroscopy, a clinically appropriate decision given her frailty and multiple comorbidities, made with patient and family agreement. During hospital admission, she received excellent documented monitoring with frequent staff assessments and her carer's presence. She deteriorated terminally with a major aspiration event and died on palliative care. The family raised concerns about tablet crushing, endoscopy, and monitoring, but hospital records demonstrated: medications were correctly given whole (oxycodone safety), the endoscopy decision was clinically sound and discussed with family, and monitoring was consistently documented. Autopsy confirmed acute oesophagitis with gastrointestinal haemorrhage as cause. This case illustrates appropriate risk-benefit analysis, shared decision-making in frail patients, and proper medication administration in disability care settings.

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