Coroner's Finding: PERTZ Zvonka

81y · Female·aspiration pneumonia on a background of severe dysphagia and right hemiplegia

An 81-year-old woman with severe dysphagia and right hemiplegia from previous stroke died of aspiration pneumonia after vomiting while sleeping following PEG feeding. She was subject to guardianship and detention under the Guardianship and Administration Act. She was discovered in distress with signs of septic shock and aspirated material. Clinical lessons include: careful patient positioning during feeding in patients with severe dysphagia; monitoring for aspiration risk; early recognition of septic shock signs; and appropriate implementation of agreed palliative care plans. The coroner found the care provided at both the nursing home and hospital to be appropriate with no identified deficiencies.