Finding into death of Mr C

55y · Male·Ascending cholangitis due to choledocholithiasis

A 55-year-old man with Down syndrome died from ascending cholangitis due to choledocholithiasis following recurrent biliary sepsis. He had multiple comorbidities including Alzheimer's disease, depression, and cardiac dysfunction, and was a specialist disability accommodation resident. He was admitted to ICU three times over several months with septic shock secondary to biliary tract infection, treated with antibiotics, vasopressors, and biliary stenting. On final admission, he deteriorated into severe septic shock and was transitioned to comfort care. The coroner found death was due to natural causes and critical illness. The case highlights the importance of early recognition and aggressive management of recurrent biliary sepsis in vulnerable patients with communication difficulties, and the need for coordinated care planning between disability services and acute hospital settings.