Finding into death of Clive John Cook

68y · Male·Complications of aspiration pneumonia in a man with intellectual disability (congenital acquired brain injury)

A 68-year-old man with severe intellectual disability and congenital brain injury died from complications of aspiration pneumonia. He had a long history of recurrent aspiration pneumonias and dysphagia. Following admission with vomiting, diarrhoea, and hypoxia, he received initial antibiotics and fluids but showed no improvement. A multidisciplinary family meeting on day 6 of admission agreed on conservative palliative care. He was transferred to palliative care where he continued to refuse oral intake and became increasingly unresponsive, dying peacefully 12 days after admission. The coroner found no causal connection between his placement in care and his death, and no preventability was suggested. Clinical lessons include recognising progressive dysphagia in intellectually disabled patients and timely transitions to palliative care with family involvement.