A coronial inquest has found Brisbane roofer Kyle Gallagher’s death was preventable after ENT specialists failed notice warning signs of his rapidly declining health.
On June 17, 2023, Brisbane man Kyle Gallagher lost control of his motorcycle, sliding into oncoming traffic and colliding with a car on Boundary Rd at Narangba, north of Brisbane.
The 22-year-old was taken to Royal Brisbane and Women’s Hospital in a serious condition with a traumatic brain injury.
Twelve days later, he discharged himself from hospital against medical advice, however, he returned later that day with pain and discomfort.
He again discharged himself against doctor’s orders on July 5, but re-presented on July 6 telling staff he was unable to cope at home.
The hospital referred him to the Surgical, Treatment and Rehabilitation Service (STARS), however the service sent him home due to a lack of beds.
Four days later, STARS contacted Mr Gallagher to advise a bed had become available.
Once admitted, the young roofer consistently complained of throat pain, struggled to speak and told his nurses he could not breathe on multiple occasions.
Mr Gallagher was declared dead on July 14, 2023 after a STARS nurse found him unresponsive and not breathing.
In the hours beforehand, Mr Gallagher was agitated, gasping for air, hyperventilating and telling those around him he was “going to die”.
A consult assessment by RBWH Ear, Nose and Throat specialists occurred only days before his death and a CT scan of his neck was ordered.
However, they did not identify any issues with his airways.
A coronial inquest into his death found the ENT clinicians failed to identify critical warning signs of his rapidly declining health, citing his cause of death as an airway obstruction due to an untreated abscess and laryngeal chondronecrosis.
The inquest found a specialised radiologist had urgently phoned the treating ENT clinician to report a “grossly abnormal larynx” on Mr Gallagher’s CT scan.
The radiologist told the inquest she could not recall seeing a larynx like Mr Gallagher’s outside the “setting of radiotherapy or potential trauma”.
The ENT specialist took the radiologist’s comments to a senior ENT consultant, however, no immediate action was taken to address the findings.
“Had an appropriate ENT assessment been undertaken, on balance, Kyle would not have died,” coroner Melinda Zerner said in her report.
“The ENT clinicians did not identify the serious compromise of Kyle’s subglottic airway, that is, that the CT scan results represented a potential acute airway problem.
“The clinicians at STARS had been falsely reassured that Kyle’s airway was ‘safe’.
“Urgent clinical assessment by an ENT surgeon of Kyle was required. This did not occur and had dire consequences.”
The coroner determined the clinicians at STARS acted “reasonably” with the information they were provided.
The coroner noted communication breakdowns and demanding clinical settings saw Mr Gallagher’s case fall through the cracks.
“There was miscommunication between (doctors) when the images were presented,” the coroner said.
“I suspect the (senior ENT) was under significant time pressure. This in addition to the miscommunication may have contributed to why he missed what was an obvious compromised (narrowed) subglottis airway with suspected chondronecrosis on the CT images.
“Whatever the reason … it set off a series of cascading events which I have determined, on balance, led to Kyle’s death.”
She voiced a need for clear communication between junior and senior staff, including senior staff establishing why they were being consulted and junior doctors escalating any concerns by the treating team.
