Finding into death of Ruben Chand
Deceased
RUBEN CHAND
Demographics
42y, male
Date of death
2009-03-22
Finding date
2012-07-16
Cause of death
Hypoxic encephalopathy in the setting of recent acute myocardial infarction with coronary artery bypass grafts
AI-generated summary
Ruben Chand, a 42-year-old male, suffered a fatal hypoxic brain injury during emergency re-intubation in ICU. After an initially reasonable extubation decision, he deteriorated and required urgent re-intubation. The procedure was complicated by a poor airway view (Grade 2B-3), inadequate pre-oxygenation, failure to use a bougie despite difficulty, lack of capnography confirmation, and critically, absence of manual bag-mask ventilation between intubation attempts. The endotracheal tube was misplaced in the oesophagus for 17-22 minutes until discovered post-arrest. Key failures: consultant not notified before re-intubation (violated hospital guidelines), difficulty information from prior hospital not transferred, no failed intubation protocol implemented. Had senior clinician been present and protocols followed, death was likely preventable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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
- 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
- The Alfred Hospital should initiate discussions with major public health services to achieve processes for conveying critical clinical information between facilities
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