Finding into death of Jennifer Rowallan Turnbull

79y · Female·Aspiration pneumonia in a woman with COVID-19 and multiple medical co-morbidities

Jennifer Turnbull, 79, with cerebral palsy and multiple comorbidities, died from aspiration pneumonia complicated by COVID-19. She was admitted to hospital in October 2022 with recurrent aspiration pneumonia. A PEG tube was inserted after discussion with family. Following accidental dislodgement during a witnessed roll-out of bed, attempts to replace feeding tubes (NGT then PEG) proved challenging; she contracted COVID-19 and declined further invasive interventions. Transition to palliative care occurred on 1 November 2022. The coroner found the hospital care reasonable and appropriate, with appropriate family involvement in decision-making. No preventability issues were identified. Key lessons: careful risk assessment before PEG insertion in aspiration-prone patients, secure tube fixation methods, and clear communication regarding patient wishes, particularly in complex disability cases.