Finding into death of Patrick Anthony Barry

72y · Male·Aspiration pneumonia and small bowel obstruction secondary to metastatic bowel cancer

Patrick Barry, a 72-year-old man with intellectual disability, severe dysphagia, and metastatic bowel cancer, died from aspiration pneumonia and small bowel obstruction. He had recurrent respiratory tract infections and presented to hospital on 18 June with shortness of breath and abdominal distension. CT imaging revealed small bowel obstruction, possible pulmonary embolus, and metastatic disease. Following family discussion, palliative management was provided given the non-surgical nature of his malignancy. The coroner found no clinical mismanagement by treating clinicians or disability support staff. Key learning points: recognising the palliative trajectory in advanced malignancy, managing aspiration risk in severe dysphagia, and appropriate multidisciplinary decision-making with families regarding end-of-life goals of care.