Coroner's Finding: Gibson, Roger Alan

65y · Male·aspiration pneumonia

Roger Alan Gibson, a 65-year-old man with advanced Alzheimer's disease and severe behavioural disturbance, died from aspiration pneumonia at the Roy Fagan Centre. He had been admitted following escalating aggression requiring medication adjustments including antipsychotics and sedatives. In mid-July 2020, he developed pneumonia with respiratory decline despite treatment. The coroner found the standard of care was entirely appropriate, with nothing further that could have been done. No clinical errors, communication failures, or preventable factors were identified. Staff attempted supportive measures including suctioning near the end of life.