Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia following intubation at Werribee Mercy Hospital. He presented with acute abdominal pain and vomiting, imaging suggested small bowel obstruction, and he became agitated during nasogastric tube insertion. Ketamine was administered for sedation, he vomited and aspirated during tube placement, requiring emergency intubation. Despite seven weeks of ICU care with comprehensive multidisciplinary investigation and treatment including bronchoscopies, imaging, and trials of NMS-specific therapies, he developed aspiration pneumonia and progressive respiratory failure. The Coroners Prevention Unit confirmed care was appropriate and thorough with no deficiencies identified. Clinical lessons include recognition that sedation and intubation were necessary given his acute presentation and behaviour, and that aspiration risk in agitated patients requiring airway intervention requires immediate management.