Finding into death of John Francis Flynn

69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm rupture and haemorrhage

69-year-old male with tonsillar squamous cell carcinoma presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-recognised despite clinical assessment noting significant risk if bleeding recurred. Missed opportunities included delayed senior ENT consultation, failure to secure airway electively before catastrophic bleed, and suboptimal escalation. Massive haemorrhage occurred, requiring emergency cricothyrotomy and resuscitation. Subsequent hypoxic-ischaemic brain injury proved fatal. Hospital review identified under-recognition of airway threat and communication delays. New protocol now mandates pre-emptive tracheostomy for post-chemoradiotherapy oropharyngeal bleeds. Key lessons: recognise sentinel airway risk, escalate senior expertise early, secure airway before life-threatening haemorrhage.