Finding into death of Joanne Margaret Burgess

50y · Female·Aspiration pneumonia secondary to aspiration of PEG feeds

Joanne Margaret Burgess, a 50-year-old woman with acquired brain injury, epilepsy, and inability to swallow, died from aspiration pneumonia secondary to PEG feed aspiration. She had required PEG feeding since 2010 but developed recurrent regurgitation problems from early 2012 despite management changes including conversion to metered mechanical feeding. She was admitted to hospital in November 2012 with aspiration pneumonia and further complications. Due to her weakened condition, she was not medically fit for surgery to insert an alternate feeding tube and was palliated. The coroner found that appropriate care was provided at both the residential facility and hospital, with no preventable errors identified.