Finding into death of Andrew John Martin

57y · Male·Aspiration pneumonia complicating large bowel volvulus in a man with chronic dysphagia and cerebral palsy

Andrew John Martin, aged 57 with cerebral palsy and chronic dysphagia, was admitted with large bowel volvulus managed conservatively per advance directives. After clinical improvement, he was transferred to palliative care at Wantirna Health for observation before returning to disability accommodation. His swallowing was further impaired post-illness. He developed aspiration pneumonia on day 20 of admission and died receiving comfort-focused care consistent with his documented wishes. The coroner found no want of clinical management or care by hospital or disability support staff. This case highlights the complex decision-making in managing bowel obstruction in severely disabled patients, the role of advance directives in guiding care, and the importance of close coordination between hospitals, palliative services, and disability support providers when managing high-risk patients with multiple comorbidities.