Finding into death of Rosemary Auchettl

52y · Female·Respiratory failure due to recurrent aspiration pneumonia; Down syndrome as underlying condition

Rosemary Auchettl, a 52-year-old woman with Down syndrome and profound intellectual disability, died from respiratory failure secondary to recurrent aspiration pneumonia while in residential care. She had a documented history of chronic aspiration pneumonia and pulmonary fibrosis requiring multiple hospital admissions. She was discharged from hospital on 30 June 2010 on a palliative care pathway with a do-not-resuscitate order in place. She died in the residential home 5 days later while seated in the lounge. Clinical lessons include the need for careful assessment of swallowing and feeding safety in patients with intellectual disability and aspiration risk, regular review of palliative care plans, and consideration of whether feeding methods and positioning strategies were optimised to minimise aspiration risk in someone with documented chronic aspiration pneumonia.