Finding into death of Hau Bui Nguyen

46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal prong use in a man with multiple co-morbidities

Hau Bui Nguyen, a 46-year-old man with severe acquired brain injury, dysphagia, and recurrent aspiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. During a 20-day hospital admission for cholangitis and aspiration pneumonia, nasal pressure injuries developed from continuous high-flow nasal oxygen. Medical staff identified this complication on 25 May and recommended transfer to a single room to use face mask oxygen instead, but this was not feasible due to COVID-19 restrictions and resource limitations. Despite conservative management including repositioning and moisturising, Hau suffered nosebleeds on 27 and 29 May. He was discharged on 2 June appearing stable, with planned ENT follow-up. After discharge, massive epistaxis occurred at his disability care facility, leading to aspiration of blood and rapid clinical deterioration. The coroner found clinical management reasonable and appropriate given constraints, with the catastrophic nosebleed at home being unpredictable at discharge.