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VICaged care2025-03-11

Finding into death of Dianne Elizabeth Harper

64y · Female·Aspiration pneumonia in a woman with multiple comorbidities

A 64-year-old woman with severe intellectual disability and multiple comorbidities died from aspiration pneumonia while in specialist disability accommodation. She had documented dysphagia and aspiration risk identified …

geriatric medicinespeech pathology
VIChospital2025

Finding into death of TBL

81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…

An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…

psychiatrygeneral practicesystemdelayrisperidone
VIChospital2024-11-08

Finding into death of S W

55y · Male·Aspiration pneumonia in the setting of cervical myelopathy, Down Syndrome and Al…

SW, a 55-year-old man with Down Syndrome, cervical myelopathy, and Alzheimer's Disease, died from aspiration pneumonia at a palliative care unit. He was admitted to hospital on 6 April 2023 after his treating neurologist…

neurologyspeech pathology
VIChospital2024-10-15

Finding into death of Melissa Joanne Dibble

53y · Female·Bronchopneumonia on a background of cerebral palsy

Melissa Dibble, aged 53, died from bronchopneumonia in the context of cerebral palsy, spastic quadriplegia, cortical blindness and progressive dysphagia due to aspiration. She was admitted to The Alfred Hospital on 27 Au…

respiratory medicinepalliative care
VIChospital2024-09-17

Finding into death of Hannah Gray

34y · Female·Aspiration pneumonia in a woman with cerebral palsy and Lennox-Gastaut syndrome

Hannah Gray, a 34-year-old woman with cerebral palsy and Lennox-Gastaut syndrome living in specialist disability accommodation, died from aspiration pneumonia. She had experienced progressive health deterioration over th…

neurologygeneral practicecannabidiol
VIChospital2024-08-30

Finding into death of Betty Eileen Cliffe

85y · Female·Asphyxia due to upper airways obstruction by mucoid plugging of the upper airway…

Betty Cliffe, 85-year-old with intellectual disability and oropharyngeal dysphagia, died from asphyxia due to upper airway mucoid plugging on a background of cardiomegaly and heart failure. She was admitted to hospital o…

respiratory medicinespeech pathology
VIChospital2024-08-07

Finding into death of Georgios Stamkos

68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…

A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised hospital meal. He had been admitted with wor…

psychiatryspeech pathologyrisperidone
VIChospital2024-06-13

Finding into death of Jennifer Rowallan Turnbull

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

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 …

general practicerespiratory medicineoral antibiotics
SAaged care2023-12-22

Coroner's Finding: LENS, Christopher

64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …

Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…

geriatric medicinespeech pathologysystemcommunication
WAhospital2023-11-17

Inquest into the Death of Child MD (Name Subject to a Suppression Order)

2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…

A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…

intensive carepaediatricsmedicationceftriaxone
VIC2023-09-08

Finding into death of Dorothy June McIntosh

55y · Female·Refractory seizures secondary to Lennox-Gastaut Syndrome (palliated)

Dorothy McIntosh, a 55-year-old woman with Lennox-Gastaut Syndrome and intellectual disability, died from refractory seizures in palliative care. She had experienced significant functional decline over 12 months, includi…

neurologypalliative caremidazolam
VIChospital2023-08-09

Finding into death of Shannon Troy Calvert

51y · Male·Aspiration pneumonia in a man with severe scoliosis and cerebral palsy

A 51-year-old man with severe scoliosis and cerebral palsy died from aspiration pneumonia. He had a documented history of aspiration risk requiring monitoring while drinking. During admission for drowsiness and hypotherm…

speech pathologyinfectious diseases
VIChospital2023-04-27

Finding into death of Yvonne Dekkers

53y · Female·Natural causes unascertained

Yvonne Dekkers, a 53-year-old woman with Down syndrome, advanced dementia, congestive cardiac failure, and severe dysphagia, died in hospital from unascertained natural causes. She had experienced progressive deteriorati…

emergency medicinepalliative caresystemcommunicationclonazepam
VIChospital2023-02-22

Finding into death of John Robert Clay

68y · Male·Stercoral perforation in a man with cerebral palsy

John Robert Clay, a 68-year-old man with cerebral palsy, died from stercoral perforation following severe constipation and faecal impaction. He had multiple complex disabilities including quadriplegia, dysphagia, and epi…

general practicegastroenterology
VIC2023-01-09

Finding into death of Andrew John Martin

57y · Male·Aspiration pneumonia complicating large bowel volvulus in a man with chronic dys…

Andrew John Martin, aged 57 with cerebral palsy and chronic dysphagia, was admitted with large bowel volvulus managed conservatively per advance directives. After clinical improvement, he was transferred to palliative ca…

general surgerypalliative care
NSWhospital2022-12-21

Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…

neurosurgeryintensive carediagnosticcommunicationtramadol
VICaged care2022-12-12

Finding into death of Lorraine Earl

71y · Female·Complications of cerebral palsy

Lorraine Earl, aged 71, died from complications of cerebral palsy at Wantirna Hospital following a palliative care pathway initiated after severe dysphagia developed during a hospital admission. The Disability Services C…

palliative caregastroenterologycommunicationsystem
VIChospital2022-12-06

Finding into death of John Sloots

58y · Male·Aspiration pneumonia in a man with Down's syndrome and dementia

John Sloots, a 58-year-old man with Down's syndrome and dementia, died from aspiration pneumonia. He had a documented longstanding swallowing impairment that had been deteriorating, and was identified as high-risk for as…

general medicinerespiratory medicine
VIChome2022-09-26

Finding into death of Gillian Patricia Johnston

65y · Female·bowel cancer

Gillian Patricia Johnston, aged 65, died from bowel cancer at her home in Wangaratta on 27 December 2020. She was residing in disability support accommodation provided by Scope Australia. Ms Johnston had received appropr…

palliative caregeneral practice
VICaged care2022-09-20

Finding into death of Tom Owen Row

59y · Male·Choking asphyxia

Tom Owen Row, a 59-year-old man with intellectual disability, dementia, Fragile X Syndrome, and Chromosome 18 Deletion Syndrome, died from choking asphyxia at a residential care facility. He had a prior choking incident …

geriatric medicinepsychiatrysystemrisperidone

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