Inquest into the death of Dr Malay Rana

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 Isaacs
• Registrar Dr Isaacs 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 Antonypillai 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

1. Establishment of a specialized ward for the care and treatment of patients diagnosed with cystic fibrosis at Westmead Hospital