Coroner's Finding: Davies, Allen William Harold

85y · Male·aspiration pneumonia due to dysphagia in a man with multiple spinal fractures and dementia

Allen William Harold Davies, 85, died of aspiration pneumonia due to dysphagia in the setting of multiple spinal fractures and dementia. He had collapsed at a hotel on 12 June 2019, was admitted to Lyell McEwin Hospital, then fell on the ward on 14 June sustaining significant cervical spine fractures. He was transferred to Royal Adelaide Hospital where he developed severe pharyngeal dysphagia and delirium requiring a Level 1 Inpatient Treatment Order. A geriatrician identified underlying neurodegenerative dementia as likely cause of dysphagia. Care was redirected to comfort care on 21 June following family discussion, and he died on 26 June 2019. Clinical management at both hospitals was found appropriate. The coroner noted his son had advised staff about fall risk and suggested bed rails, but the patient had capacity to make decisions and was alert and independently mobilising prior to his fall. No recommendations were made.