Finding into death of Ruben Chand

42y · Male·Hypoxic encephalopathy in the setting of recent acute myocardial infarction with coronary artery bypass grafts

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.