Finding into death of Christopher Mark Tognon

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Christopher Mark Tognon was a 42-year-old man with severe neurological disabilities including intellectual disability, cerebral palsy, spastic quadriplegia, blindness, and epilepsy. He was a resident in a specialist disability accommodation facility under the National Disability Insurance Scheme, where he required full assistance with all activities of daily living and was dependent on a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. On 3 August 2025, he developed fever, cough, and symptoms consistent with pancreatitis and early-stage pneumonia. He was initially assessed at Stawell Hospital but returned to his residential unit, then transferred to Wimmera Base Hospital in Horsham when his symptoms worsened. He deteriorated rapidly, developing vomiting, decreased blood pressure, comatose state, and sepsis. The medical team initiated comfort care on 4 August, and he died on 5 August 2025. The cause of death was aspiration pneumonia complicating pancreatitis, likely resulting from recurrent aspiration during vomiting despite antiemetic treatment. The coroner found the medical care provided was appropriate with no preventable errors identified.

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