A coronial inquiry has found a series of professional errors led to the death of a young man in hospital two weeks after he was injured in a car crash.
The inquest found 20-year-old Adam Fitzpatrick's injuries from the crash in regional NSW were survivable, but a dislodged tracheostomy breathing tube led him to suffer catastrophic brain failure in August 2020.
In findings handed down on Tuesday, Deputy State Coroner Derek Lee said evidence showed clinicians Paras Jain, Ajey Dixit, Hemang Doshi and Ashima Sharma might have displayed “unsatisfactory professional conduct” in failing to properly address the issue.
Three of the doctors did not exercise appropriate clinical judgement in managing Mr Fitzpatrick's tracheostomy, while Dr Sharma failed to clarify with the other clinicians about the airway treatment plan and whether there were any issues with it.
In the interest of public health and safety, a transcript of the evidence from the inquiry will be given to the Medical Council of NSW, which has the power to investigate incidents and revoke the right of medical professionals to practise.
Mr Fitzpatrick was involved in a single-vehicle crash after leaving a pub in the Riverina town of Hay in the early hours of August 8, 2020.
He was found by passersby more than seven hours after the crash and treated at Hay hospital for multiple facial and skull fractures, injuries that were deemed to be non-life threatening.
Mr Fitzpatrick was transferred to St George Hospital in Sydney for monitoring and further treatment.
A tracheostomy tube was inserted there to help him breathe.
On August 22, Mr Fitzpatrick was heard making "gurgling noises" and staff recognised he was having difficulty breathing, the inquest was told.
Steps were taken to investigate the issues, but the 20-year-old went into cardiac arrest and was later found to have suffered irreversible brain injuries.
Mr Fitzpatrick was pronounced dead on the afternoon of August 25, five days before his 21st birthday.
The case was referred to the coroner due to the time that elapsed between the crash and his death, making the exact cause unclear.
Mr Fitzpatrick's family also raised concerns about what they were told in the hours, days and months following his death by the hospital and those that treated him.
The coroner found Mr Fitzpatrick's life could have been spared if clinicians at the hospital had acted differently.
"Adam died in circumstances where dislodgement of his tracheostomy was recognised or suspected by clinicians involved in his care," Mr Lee said.
"However, timely and definitive management of the clinical situation was not instituted to remove and replace the tracheostomy tube.
"This had the consequent effect of delaying effective management of Adam’s airway and resuscitation efforts."
