Finding into death of Joseph Micallef

55y · Male·Aspiration pneumonia

Joseph Micallef, a 55-year-old man with cerebral palsy and epilepsy living in high care accommodation, died from aspiration pneumonia. He had longstanding dysphagia related to his cerebral palsy, which had caused multiple previous episodes of aspiration pneumonia. On 7 April 2012, he presented with decreased conscious state, gurgling, and shortness of breath, was admitted to Austin Hospital, treated with antibiotics, but deteriorated and died the same day. The coroner found no evidence of preventable error or system failure. Clinical lessons relate to management of aspiration risk in patients with cerebral palsy and dysphagia, recognition of aspiration pneumonia, and appropriate antibiotic therapy in acute presentation.