Finding into death of John Robert Clay

68y · Male·Stercoral perforation in a man with cerebral palsy

John Robert Clay, a 68-year-old man with cerebral palsy, died from stercoral perforation following severe constipation and faecal impaction. He had multiple complex disabilities including quadriplegia, dysphagia, and epilepsy, managed by a multidisciplinary team with constipation/bowel management plans in place. In the year before death, his health deteriorated significantly with severe constipation treated by his GP including manual evacuation. On 29 July 2020, he presented acutely with abdominal distension, fever, and absent bowel movements for four days. Imaging revealed large pneumoperitoneum with faecal loading. A decision was made to provide palliative care rather than surgical intervention, given his poor prognosis and compromised health. The coroner found the medical care received was reasonable and appropriate, and that his status 'in care' did not contribute to his death. No failures in care management were identified.