Coronial

292 results for dysphagia

WAmental health2018-09-19

Inquest into the Death of Wlodzimierz DUDEK

69y · Male·bronchopneumonia and hypoxic brain injury following aspiration of food (choking)

…al and supervision was reasonable, as choking was not identified as a risk despite a previous episode of dysphagia documented four months earlier that had apparently resolved. The key clinical lesson is that documented …

psychiatryemergency medicinecommunicationsystem
VIChospital2023-06-25

Finding into death of Peter John Weatherly

63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…

A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital adm…

general medicineemergency medicinesystemcommunicationrisperidone
VICcommunity2026-04-13

Finding into death of David Evan Wild

61y · Male·Natural causes unascertained

…line with multiple comorbidities including recurrent urinary tract infections, aspiration pneumonia, and dysphagia. He was discharged from hospital on 14 April 2025 following aspiration pneumonia treatment and died unex…

geriatric medicineneurologyfluoxetine
VIC2026-03-19

Finding into death of Judith Gail Longhurst

74y · Female·Chronic obstructive pulmonary disease

Judith Gail Longhurst, a 74-year-old woman with cerebral palsy, dysphagia, and multiple comorbidities, died of chronic obstructive pulmonary disease (COPD) on 23 October 2024 at …

respiratory medicinegeneral practicesertraline
NThospital2021-01-07

Inquest into the death of Edgar Forrester

56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…

…y to oesophageal squamous cell carcinoma with metastases while in custody. He presented with progressive dysphagia from September 2019, initially managed as benign (dental abscess, rib fracture). Critical delay occurred…

general practicecardiologydiagnosticdelay
VIChospital2022-02-28

Finding into death of Stephen David Johnston

64y · Male·Aspiration pneumonia with cerebral palsy as a contributing factor

A 64-year-old man with cerebral palsy, intellectual disability, dysphagia, and recurrent respiratory infections died of aspiration pneumonia. He was receiving disability support …

general practicepalliative caresystem
QLDhome2026-02-03

Inquest into the death of Bridie Gilligan

42y · Female·Hypoxic brain injury due to choking on food, with Cornelia de Lange Syndrome con…

Bridie Gilligan, 42, with Cornelia de Lange Syndrome, intellectual disability, and dysphagia, choked on a Yumbo burger in her Supported Independent Living accommodation on 29 April 2021, suffering …

speech pathologydieteticssystemcommunication
VIChospital2024-10-11

Finding into death of Maria Presti

62y · Female·Aspiration pneumonia secondary to cerebral palsy

Maria Presti, 62-year-old non-verbal woman with cerebral palsy and dysphagia living in specialist disability accommodation, died from aspiration pneumonia with acute kidney injury a…

respiratory medicineinfectious diseasesantibiotics
VIC2023-08-17

Finding into death of Peter Stuart Jamieson

57y · Male·Small bowel obstruction due to mid small bowel volvulus

Peter Jamieson, a 57-year-old man with multiple chronic conditions including dysphagia and constipation, was residing in a disability care facility. On 6 July 2022, he developed diarrhoea, re…

general practiceforensic medicinediagnosticamoxicillin
VIChospital2013-05-09

Finding into death of Argyrios Carras

38y · Male·Aspiration pneumonia in the setting of cerebral palsy

… supported accommodation contributed to his death. Key clinical lesson: patients with cerebral palsy and dysphagia require careful monitoring for aspiration risk, and early recognition of respiratory decline is essentia…

respiratory medicineinfectious diseasesdiazepam
VICaged care2014-12-15

Finding into death of Terence Joseph Roadley

63y · Male·Complications of disseminated tumour (primary site unknown)

…admitted to McKenna House Palliative Care Unit on 29 December 2013 for end-of-life care due to worsening dysphagia and aspiration pneumonia. The coroner found the healthcare provided by his general practitioner, Norther…

palliative caregeneral practicemetoclopramide
VICaged care2015-05-08

Finding into death of Gregory Donald Cole

50y · Male·Cerebral hypoxia and bronchopneumonia post episode of choking

…was a Wyndham Lodge aged care resident with significant disabilities including post-stroke paralysis and dysphagia requiring modified diet. He died on 25 June 2009 from cerebral hypoxia and bronchopneumonia following as…

speech pathologysystemcommunication
VIChospital

Finding into death of Ella Felicity Hitchen

32y · Female·Aspiration pneumonia with severe cerebral palsy as underlying condition

…woman with severe cerebral palsy, quadraplegia, intellectual disability, vision impairment, epilepsy and dysphagia who died from aspiration pneumonia. She had a PEG tube inserted in 2011 due to aspiration risk. Followin…

respiratory medicinegeneral medicine
VICaged care2022-01-12

Finding into death of Diane Maree Pearse

51y · Female·Status epilepticus on a background of Lennox Gastaut syndrome and cerebral palsy

…d severe cerebral palsy, died from status epilepticus after prolonged deterioration. She had progressive dysphagia and recurrent seizures despite multiple anti-epileptic medications. A PEG tube was deemed too high-risk …

neurologypalliative careclonazepam
ACTaged care2020-06-02

Inquest into the death of VIOLA DIANA CLARKE

86y · Female·aspiration pneumonia

… with multiple comorbidities including congestive heart failure, COPD, renal failure, gastric reflux and dysphagia, died from aspiration pneumonia. She was administered incorrect medication at her aged care facility on …

geriatric medicinerespiratory medicinemedication
VIChospital2024-09-17

Finding into death of Hannah Gray

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

…ital staff. Her death resulted from natural causes related to her underlying neurological conditions and dysphagia.

neurologygeneral practicecannabidiol
VIChospital2023-10-16

Finding into death of Adam Richard Greaves

48y · Male·Aspiration pneumonia complicating progressive degenerative neurological disorder…

…, a 48-year-old man with progressive degenerative neurological disorder, frontotemporal dementia, severe dysphagia, and cerebral palsy, died from aspiration pneumonia after admission to hospital with acute breathing dif…

emergency medicineneurology
VIChospital2010-06-21

Finding into death of Ashley William Seedsman

34y · Male·Septic shock from aspiration pneumonia; cerebral palsy was a contributing condit…

… and he died on 30 July 2009. Clinical lessons include recognition that patients with cerebral palsy and dysphagia require careful monitoring of feeding tolerance, prompt recognition of aspiration signs (laboured breath…

emergency medicinegeneral medicine
VIChospital2025-08-11

Finding into death of JBL

73y · Male·Multiorgan dysfunction in the setting of severe heart failure in a man with mult…

…preventability findings. Clinical lessons include careful management of aspiration risk in patients with dysphagia and intellectual disability, attention to nutritional and functional decline, and appropriate timing of …

geriatric medicinecardiology
VIChospital2023-02-22

Finding into death of John Robert Clay

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

…g severe constipation and faecal impaction. He had multiple complex disabilities including quadriplegia, dysphagia, and epilepsy, managed by a multidisciplinary team with constipation/bowel management plans in place. In…

general practicegastroenterology
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