Inquest into the death of Master F

17y · Male·pneumonia and respiratory failure associated with choreoathetoid cerebral palsy

A 17-year-old Indigenous male with severe choreoathetoid cerebral palsy, feeding difficulties, and swallowing dysfunction died of pneumonia and respiratory failure in ICU. He had missed lunch medications (Baclofen and Gabapentin) on two occasions 8-9 days prior to admission due to logistical errors. Expert review by his paediatrician determined these omissions were unlikely to have contributed to his death. The clinical team provided appropriate care including resuscitation, ICU management, and respect for the patient's expressed wishes regarding intubation. The coroner found no deficiencies in care, noting excellent support from disability services. This case highlights the complexity of managing a severely disabled young person with respiratory vulnerability and the importance of medication administration protocols in specialist disability care.