Finding into death of Gregory Charles Shufflebotham

AI-generated summary

Gregory Charles Shufflebotham, aged 69 years, died on 21 February 2026 from pneumonia complicating end-stage liver cancer. He had moderate intellectual disability and resided in a supported independent living facility in Werribee, Victoria. In December 2025, a dietician identified severe dysphagia with high aspiration risk, and he was placed on a thickened fluid diet. He was hospitalized 19 December 2025 with aspirational pneumonia, treated, and rehabilitated before discharge on 6 February 2026. His condition gradually deteriorated at home from 15 February onwards, with an advanced care plan prepared on 20 February. He was found unresponsive on his bedroom floor on 21 February and died shortly after. Post-mortem examination confirmed the clinical diagnosis. The coroner found no evidence of clinical error or preventable factors in his management. This case illustrates the complex management challenges in elderly patients with intellectual disability, severe swallowing disorders, and advanced malignancy, particularly highlighting the importance of early dysphagia assessment, appropriate dietary modification, and timely advance care planning.

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