Finding into death of Matthew Glenister Blake Clark

51y · Male·Complications of Recurrent Small Bowel Obstruction (palliated)

Matthew Clark, 51, with Down syndrome and chronic liver disease secondary to Hepatitis B, died from complications of recurrent small bowel obstruction. He had undergone emergency surgery in June 2018 for a perforated bowel with foreign body (suspected chicken bone) complicated by sepsis and pneumonia. Despite recovery and discharge, he re-presented in July with recurrent symptoms requiring prolonged hospitalisation. The coroner's independent review by the Coroners Prevention Unit found no issues with medical management or healthcare provision. Matthew had appropriate dietary restrictions in place for his narrow oesophagus and was palliatively managed in his final admission. The death appears to reflect the natural progression of his complex medical conditions rather than any preventable medical error.