Finding into death of Maryanne Gordon

69y · Female·Complications of oesophageal squamous cell carcinoma (palliated)

Maryanne Gordon, a 69-year-old woman with intellectual disability and Lewy body dementia living in NDIS-funded supported accommodation, presented with dysphagia and weight loss. Gastroscopy revealed oesophageal squamous cell carcinoma with severe stricture. She was deemed not suitable for curative treatment; palliative stenting offered limited utility. Following a family meeting, end-of-life comfort care was initiated, and she was transferred to hospice where she died 10 days later from complications of her malignancy. The coroner found no clinical management failures by the accommodation operator. This case highlights the importance of early recognition of dysphagia and weight loss in vulnerable populations, appropriate goals-of-care discussions with families, and timely palliative care transitions.