Coroner's Finding: Leditschke, John Murray

79y · Male·acute aspiration of food on a background of Alzheimer's dementia

John Murray Leditschke, aged 79 with Alzheimer's dementia, died from acute aspiration of food while eating in hospital. He was admitted to Lyell McEwin Hospital on 22 March 2023 with low oxygen saturation and suspected pneumonia, receiving appropriate treatment. On 25 March, while being fed custard, he aspirated. Staff immediately raised an emergency alarm, and nursing staff suctioned his airways and performed back blows. Dr S. arrived within two minutes but found no pulse or breathing effort. He had an Advance Care Directive prohibiting resuscitation and intubation. The coroner found death resulted from acute aspiration on a background of Alzheimer's dementia, with food material confirmed in the airways at post-mortem. The coroner found the aged care facility appropriately identified his decline and transferred him to hospital, hospital care was prompt and appropriate, and the aspiration could not have been prevented—he had no prior swallowing difficulties and had been eating regular meals without incident. No clinical errors were identified. No recommendations were made.