Coroner's Finding: Zarrella, Dominic

88y · Male·aspiration pneumonia complicating vascular dementia and metastatic prostate cancer

An 88-year-old man with vascular dementia, metastatic prostate cancer, and chronic kidney disease died of aspiration pneumonia 15 days after admission to hospital under a Mental Health Act inpatient treatment order. He was admitted following refusal of food, fluids and medications. During his stay he developed complications including dehydration, fluid overload, respiratory distress, and a small subdural haematoma (discovered on day 11, possibly from an unwitnessed fall). He was transitioned to end-of-life care on day 12 after developing fever and infective infiltrates consistent with aspiration pneumonia. The coroner found the standard of care was appropriate and made no recommendations, though expressed concern about scant documentation of a potential in-hospital fall.