Finding into death of Johannes Gerhardus Jansen

66y · Male·Aspiration pneumonia complicating a seizure in a man with dysphagia and phenylketonuria

A 66-year-old man with phenylketonuria and intellectual disability died from aspiration pneumonia complicated by seizure following missed anti-epileptic medications at his residential care facility. He presented to St Vincent's Hospital in status epilepticus with aspiration pneumonia, where his Glasgow Coma Scale fluctuated between 5-9 despite active treatment including IV antibiotics and multiple MET calls. He was palliated on 24 February and died on 28 February 2019. The critical clinical lesson is the importance of ensuring continuity of anti-epileptic medication in patients with severe intellectual disability residing in care facilities. Missed medications directly led to status epilepticus, which precipitated the fatal aspiration event. Care facilities must have robust medication management systems, particularly for patients with seizure disorders and dysphagia.