Finding into death of Ruben Chand

Contributing factors

• Failure to notify consultant before re-intubation attempt, violating hospital guidelines
• Lack of knowledge of previous difficult intubation at Royal Melbourne Hospital
• Poor airway view (Grade 2B-3) not adequately managed
• Inadequate pre-oxygenation due to patient agitation
• Failure to use bougie when called for, receiving introducer instead
• Misplaced endotracheal tube in oesophagus for 17-22 minutes
• No capnography confirmation of tube placement
• Failure to implement failed intubation protocol
• Absence of manual bag-mask ventilation between intubation attempts
• Poor task allocation and disorganised procedure
• Consultants not informed of intubation difficulties or lack of confirmation

Coroner's recommendations

1. When a patient is transferred from one public hospital to another, information about their intubation status and any difficulty with intubation should be recorded and conveyed to the receiving hospital
2. The Alfred Hospital should initiate discussions with major public health services to achieve processes for conveying critical clinical information between facilities