Inquest into the death of Kyle James Gallagher

Contributing factors

• Failure of ENT consultant to appropriately review CT scan showing 3mm subglottic airway narrowing and suspected chondronecrosis
• Inadequate communication between junior ENT doctor and senior ENT consultant regarding seriousness of imaging findings
• Junior ENT registrar did not review CT radiologist report before initial consultation with ENT consultant
• Junior ENT registrar did not review STARS clinical records before consulting senior ENT doctor
• Failure to escalate clinical concerns when rehabilitation team reported worsening stridor at 1.14pm on 13 July
• Inappropriate placement of patient with acute airway compromise in rehabilitation setting rather than acute hospital
• Nursing staff misinterpreted progressive respiratory distress as anxiety related to brain injury
• Administration of sedative and opioid medications that suppressed respiratory drive in setting of obstructed airway
• Delay in commencing CPR (6 minutes) though this did not affect outcome
• ENT team provided false reassurance that airway was 'safe' without appropriate clinical assessment

Coroner's recommendations

1. Clear communication protocols must be established between junior and senior medical staff regarding consultations
2. Senior medical staff must establish the basis on which they are being consulted by junior doctors and not assume informal reviews of imaging
3. ENT consultants must review radiologist reports in addition to reviewing raw imaging, particularly in complicated cases
4. Junior doctors must review complete clinical records and escalate concerns when contacted by treating team about patient deterioration
5. Immediate commencement of CPR when resuscitation plan for a patient is unknown
6. Patients with documented stridor and imaging evidence of airway narrowing must be transferred to acute hospital facilities, not managed in rehabilitation settings
7. Clear escalation protocols for patients with potential airway compromise, particularly in rehabilitation settings
8. Recognition that sedative and opioid medications can mask signs of respiratory distress in patients with obstructed airways