Finding into death of Susan Elizabeth Czudar

63y · Female·1a: Aspiration pneumonia in a woman with acquired brain injury, 1b: Cerebrovascular disease

Susan Czudar, 63, died of aspiration pneumonia complicated by acquired brain injury from a 2017 subarachnoid haemorrhage and multiple strokes. Residing in NDIS-funded specialist disability accommodation, she was admitted 20 March 2025 with COVID-19 and reduced consciousness, transferred to palliative care 25 March. A February 2025 videofluoroscopic swallowing study identified high aspiration risk and indicated need for percutaneous gastrostomy. The clinical team engaged the family in shared decision-making about risks, benefits, quality of life, and goals of care. With informed consent, the family chose comfort-based management and continued oral feeding. On 16 April, acute aspiration with desaturation to 85% was managed with oxygen and comfort medications aligned with her wishes. She died 18 April. The coroner found no clinical deficiency, demonstrating this case as an exemplar of risk-aware, family-centered end-of-life care decision-making.