Inquest into the death of Phillip Ibrahim

39y · Male·Hypoxic/Ischaemic Encephalopathy due to Cerebral Arterial Gas Embolism

Phillip Ibrahim, a 39-year-old man recovering well from community-acquired pneumonia in ICU, suffered a fatal cerebral air embolism on 28 October 2014. A CVAD removal order was given at midday but the device remained in place for 6+ hours while Phillip sat out of bed with family visitors. An IV line disconnected from the Multi Flow Extension Set, allowing air entry into the CVAD. Critical failures included: delayed CVAD removal due to lack of nursing prioritisation and unclear communication of the 'deline' order; failure to clamp or remove unused extension lines despite NSW Health policy; and inadequate medical oversight of the removal plan. A junior registrar had opportunity to intervene but did not. The coroner found the death preventable—timely removal of the extension set and clamping of lumens would have prevented the embolism. Key lessons: establish clear timeframes for CVAD removal, maintain high credentialing rates, remove unnecessary lines promptly, ensure robust handover communication, and prioritise device safety over patient convenience.