Finding into death of Beryl Maloney

76y · Female·Aspiration pneumonia and cholangitis; obstructive jaundice from intraduct tumour in a woman with cerebral palsy

76-year-old woman with cerebral palsy, dysphagia, and PEG feeding died from aspiration pneumonia and cholangitis secondary to an obstructive bile duct tumour. She was admitted with obstructive jaundice and sepsis, underwent ERCP procedures for bile duct obstruction and stent insertion. Despite antibiotic therapy and supportive care including transfusion and oxygen therapy, she developed progressive aspiration pneumonia and fluid overload, deteriorating to death on a palliative pathway. The coroner found no deficiencies in hospital care or disability services provision. Clinical lessons include the complexity of managing aspiration risk in patients with dysphagia receiving PEG feeds, the importance of monitoring for fluid overload post-transfusion in elderly patients, and the challenging interplay between biliary obstruction, infection, and aspiration pneumonia.