Finding into death of Reginald William Griggs

84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical treatment of recurrent nasal squamous cell carcinoma

An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be actively sought and documented during pre-operative assessment, particularly in elderly patients with comorbidities; (2) Goals of Care discussions should occur early and be clearly documented; (3) tracheostomy decannulation in high-risk patients requires careful multidisciplinary assessment, which was undertaken appropriately here; (4) communication with families about complications and treatment plans needs improvement in multi-team settings. The coroner found the medical management reasonable but identified systemic failures in ACP awareness and documentation that delayed appropriate palliative care initiation.