Finding into death of Marco Angelo Virgona

45y · Male·Aspiration pneumonia with acquired brain injury as a contributing factor

Marco Virgona, a 45-year-old man with acquired brain injury and epilepsy, died from aspiration pneumonia at Frankston Hospital on 23 May 2017. He initially presented to Ambulance Victoria in the morning with vomiting and diarrhoea, which paramedics assessed as likely gastroenteritis. They did not transport him to hospital based on clinical observations that the vomit appeared to contain food matter rather than blood. However, his condition deteriorated markedly by afternoon with respiratory distress, and he was then appropriately transported to hospital. At hospital, he was intubated for respiratory support but suffered a cardiac arrest during the procedure, with initial misplacement of the endotracheal tube. The coroner found all clinical management by paramedics, Yooralla staff, and hospital to be reasonable and appropriate, noting that key clinical differences between morning and afternoon presentations (absence of respiratory distress, altered consciousness, and gurgling breathing in the morning) justified the initial decision not to admit.