Finding into death of Deborah Jane Parker

61y · Female·aspiration pneumonia

A 61-year-old woman with intellectual disability, wheelchair-bound, and living in supported accommodation died from aspiration pneumonia following community-acquired pneumonia treated in July 2016. She was discharged, then attended her GP three times over two weeks for respiratory symptoms (wheezing, chest infection) treated with antibiotics and bronchodilators. She deteriorated with worsening dyspnoea, productive cough, and reduced oral intake. Re-admitted with aspiration pneumonia, type 2 respiratory failure, acute kidney injury, and delirium, she failed to improve despite intravenous antibiotics and was transitioned to palliative care. The coroner found no causal relationship between her death and her status as a person in care, and found care provision reasonable and appropriate. No imaging (chest X-ray) was documented during the inter-hospital period despite recurrent respiratory symptoms in a high-risk patient.