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Content Warning

Contains: death in care settings, medical neglect

safeguardingcommunication barriersservice gapsresidential caremedical oversight

Robert's Support Outcomes Were Under Review.

Based on Victorian Coroner's FindingAI-Assisted Summary

Robert, aged 63, resided in Specialist Disability Accommodation. He had an NDIS plan for daily independent living support.

Robert, aged 63, had a diagnosis of schizophrenia, epilepsy, intellectual disability, frontotemporal dementia, and hypothyroidism. Since 2012, he had multiple hospital admissions for declining health. From 2014 until September 2021, he lived in a hospital unit.

On 15 September 2021, Robert moved to Specialist Disability Accommodation, operated by a registered NDIS provider. He received funded daily independent living support. By 2025, Robert was non-verbal and had difficulty swallowing. A guardian had been appointed.

In 2024, Robert developed a lip lesion from habitual biting. His carers raised concerns with his general practitioner. On 22 November 2024, a referral was made to a skin cancer clinic. Biopsies were performed on 29 January 2025, and he was referred for further assessment.

On 9 March 2025, Robert was admitted to a hospital following a seizure. He was treated for functional decline and malnutrition. On 24 March 2025, he was transferred for surgery to remove the lip lesion. The procedure was successful.

A speech pathologist recommended a nasogastric tube for nutrition. His carers and a family member expressed concern given his cognitive capacity. Consent was given for the tube on 27 March 2025.

On 28 March 2025, Robert removed the tube. It was replaced on 29 March 2025. On 30 March 2025, Robert began coughing and developed hypoxia, with an X-ray showing aspiration. His feeds were paused. His prognosis was deemed poor, and comfort care was recommended. His carers were accepting.

I would be interested to understand how Robert’s habitual lip biting was managed in the context of his NDIS support.

Robert died on 31 March 2025. The cause of death was aspiration pneumonia complicating lip excision and reconstruction for squamous cell carcinoma.

Source: Original Document (opens in new tab) (COR 2025 001734)

Related to:

intellectual disabilityschizophreniaepilepsyfrontotemporal dementiahypothyroidismacquired brain injurycomplex communication needs

Topics:

NDISSDAcoronerdeath-in-caresafeguardingaspiration-pneumoniacomplex-needsadvocacydisability-rightsVictoria

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