Inquest into the death of Dr Malay Rana

27y · Male·Loss of airway control and blockage due to aspiration from complications of a small bowel obstruction

Dr R., a 27-year-old physician with cystic fibrosis, died from aspiration and airway blockage secondary to a small bowel obstruction whilst under dual respiratory-surgical care at Westmead Hospital. Critical clinical lessons include: (1) failure to maintain clear dual-team communication and decision-making authority, resulting in junior doctors believing respiratory team held primary care; (2) inadequate escalation of clinical deterioration despite objective warning signs including tachycardia (130), fever (39.4°C), elevated lactate, and imaging changes; (3) premature removal of nasogastric tube (NGT) without sufficient safeguards or written senior guidance for reinsertion; (4) failure of senior registrars to conduct personal reviews when indicated; and (5) opioid analgesia (fentanyl) masking infection symptoms. Multiple missed opportunities to escalate to MET/rapid response or reinsert NGT during evening of 27 April and early 28 April.