Inquest into the death of Dr Malay Rana
Deceased
Dr Malay Rana
Demographics
27y, male
Date of death
2015-04-28
Finding date
2018-06-06
Cause of death
Loss of airway control and blockage due to aspiration from complications of a small bowel obstruction
AI-generated summary
Dr R., a 27-year-old physician with cystic fibrosis, died from aspiration and airway blockage secondary to a small bowel obstruction whilst under dual respiratory-surgical care at Westmead Hospital. Critical clinical lessons include: (1) failure to maintain clear dual-team communication and decision-making authority, resulting in junior doctors believing respiratory team held primary care; (2) inadequate escalation of clinical deterioration despite objective warning signs including tachycardia (130), fever (39.4°C), elevated lactate, and imaging changes; (3) premature removal of nasogastric tube (NGT) without sufficient safeguards or written senior guidance for reinsertion; (4) failure of senior registrars to conduct personal reviews when indicated; and (5) opioid analgesia (fentanyl) masking infection symptoms. Multiple missed opportunities to escalate to MET/rapid response or reinsert NGT during evening of 27 April and early 28 April.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Small bowel obstruction with adhesions from prior surgery
- Premature removal of nasogastric tube without adequate safeguards
- Failure of communication between respiratory and surgical teams regarding dual care model
- Junior doctors believing respiratory team held primary care despite stated dual care arrangement
- Failure to recognise clinical deterioration on evening of 27 April despite objective warning signs
- Inadequate clinical review and escalation by surgical registrar Dr I.
- Registrar Dr I. did not examine patient or access medical records during telephone consultation
- Failure to reinsert NGT despite increasing abdominal distension and discomfort
- Opioid analgesia (fentanyl) masking pain symptoms indicative of sepsis
- Lack of clear senior direction regarding NGT reinsertion criteria
- Failure to contact on-call respiratory consultant at critical junctures
- Nursing staff failure to activate PACE/escalation calls despite deterioration
- Registrar Dr A. failure to recognise deterioration at 5am review, final clinical opportunity to escalate care
- Prior undiagnosed aspiration event related to small bowel obstruction
Coroner's recommendations
- Establishment of a specialized ward for the care and treatment of patients diagnosed with cystic fibrosis at Westmead Hospital
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