Deceased
Glenn Richard Altmann
Demographics
50y, male
Coroner
Coroner John Olle
Date of death
2014-04-07
Cause of death
aspiration pneumonia (with Down syndrome as contributing condition)
AI-generated summary
Glenn Altmann, a 50-year-old man with Down syndrome, epilepsy, cognitive impairment and oropharyngeal dysphagia, died from aspiration pneumonia. He was under palliative care in the community following a January 2014 diagnosis of aspiration pneumonia and oropharyngeal dysphagia with absent cough/gag reflex. A clear palliative care plan was established with his family and DHS staff, prioritising comfort over aggressive feeding interventions, recognising that aspiration was inevitable and some episodes would result in infection. On 7 April 2014, his condition deteriorated and he was transferred to the palliative care ward where he died that evening. The care provided was appropriate and aligned with an agreed palliative approach. No clinical errors or preventable failures were identified.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
AT MELBOURNE Court Reference: COR 2014 1806
Form 38 Rule 60(2) Section 67 of the Coroners Act 2008
I, JOHN OLLE, Coroner having investigated the death of GLENN RICHARD ALTMANN without holding an inquest:
find that the identity of the deceased was GLENN RICHARD ALTMANN
born on 24 September 1963
and the death occurred on 7 April 2014
at South West Healthcare, Ryot Street Warrnambool VIC 3280
from:
(a) ASPIRATION PNEUMONIA
1(b) DOWN SYNDROME
Pursuant to Section 67(1) of the Coroners Act 2008, I make these findings with respect to the
following circumstances:
He is survived by his sister Carol Altmann, with whom he maintained a close and loving
relationship.
patient.
West Healthcare, in the context of gradual decline with weight loss. In January 2014 he was
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observed to have a decreased Glasgow Coma Scale with associated ‘gurgly’ moist breath sounds and raised inflammatory markers. He had recently lost some weight, his function continued to decline, he had increasing periods of reduced conscious state and had difficulty feeding. Mr Altmann was diagnosed with aspiration pneumonia, was recommended level 2 (moderately thick) fluids and pureed diet and was given intravenous antibiotics, however due to Mr Altmann attempting to remove the cannula he was changed over to syrup Augmentin Duo, with good effect. He was also diagnosed with oropharyngeal dysphagia which had been
an ongoing issue as Mr Altmann had very little, if any cough/gag reflex.
Due to Mr Altmann’s deteriorating state DHS staff and Mr Altmann’s family discussed palliative care approaches, including hospitalisation. Due to Mr Altmann being distressed by hospitals, it was decided that he be cared for in his DHS accommodation with a palliative approach. DHS staff and treating clinicians had discussions with Mr Altmann’s family and explained that aspiration will always be an issue for Mr Altmann, that he will aspirate on his own saliva and that some of the episodes will have little consequence and others may result in an infection or pneumonia. It was recommended to DHS staff and treating clinicians that if Mr Altmann was drowsy, could not sit upright or was too fatigued to eat that they do not need to wake or force feed him, which may result in him not drinking or eating for the whole day, but that the priority was to provide quality of life, not quantity. This plan was agreed to by family and staff. The focus was on Mr Altmann’s comfort. Community palliative care assisted the DHS carers with Mr Altmann’s medical care needs and the general practitioner managed
episodes of aspiration and other medical issues requiring a doctor.’
On the morning of 7 April 2014 Mr Altmann’s condition deteriorated, The house supervisor notified the palliative care team doctor, Dr Emma Greenwood, and Mr Altmann’s sister Carol.
Dr Greenwood arranged for Mr Altmann to be transferred to the palliative care ward at South West Health Care. Mr Altmann’s condition continued to deteriorate throughout the day and
Mr Altmann passed away at 8.45pm with Carol in attendance.”
A post-mortem inspection and report was undertaken by Dr Paul Bedford, Forensic
Pathologist at the Victorian Institute of Forensic Medicine. Dr Bedford reported that there was
| Discharge summary, South West Health Care.
? Department of Human Services Client Incident Report Form, dated 11 April 2014.
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a recent history of issues relating to the brain and development of seizures with general deterioration and then a complication of aspiration pneumonia leading to death. No suspicious
circumstances were noted.
aspiration pneumonia and 1(b) Down syndrome.
required, I am satisfied that there are no suspicious circumstances.
I direct that a copy of this finding be provided to the following: The family of Glenn Altmann; Investigating Member, Victoria Police; and
Interested parties.
Signature:
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