Finding into death of Lachlan Rayner

44y · Male·Airways obstruction with mucous plugging secondary to quadriplegia post accident

Lachlan Rayner, a 44-year-old man with quadriplegia from a 2019 spinal injury, died from airways obstruction due to mucous plugging and pneumonia. He was a specialist disability accommodation resident receiving in-home care. On 8 June 2023, carers identified hypotension and absent urine output; an ambulance was called at 7:39am but not dispatched until 9:28am, arriving at 10:30am. On hospital arrival, oxygen saturation was critically low at 40% with severe left lower lobe collapse. Despite aggressive management, the mucous plug could not be removed and he deteriorated rapidly, transitioning to end-of-life care. The coroner found no want of clinical management contributed to death, though noted the ambulance delay. The case highlights risks of respiratory compromise in immobile patients and importance of early recognition of deterioration in this vulnerable population.