Man's death 'precipitated' by head injury from collapsed stretcher in medical misadventure: Coroner - CNA

2022-09-24 03:41:54 By : Ms. Lucy Cheng

File photo of the State Courts in Singapore (Photo: Jeremy Long)

SINGAPORE: A 55-year-old man who died of a heart attack and bleeding in the brain was being transferred between hospitals when a stretcher he was strapped into collapsed at arrival, causing a traumatic head injury, a coroner has found.

In findings made available on Tuesday (Apr 13), State Coroner Kamala Ponnampalam found that Mr Razib Bahrom's head injury is believed to have "precipitated his further decline, which progressed rapidly leading to his demise".

She ruled his death an unfortunate medical misadventure and recommended that hospitals revisit this event and form specific guidelines to address the transfer of patients in similar circumstances and make appropriate provisions such as a larger ambulance or emergency vehicle that could accommodate all necessary staff.

The court heard that Mr Razib went to Khoo Teck Puat Hospital at 9pm on Jun 17, 2018, after experiencing worsening chest pains.

He was diagnosed with acute myocardial infarction, or a heart attack, and underwent procedures that same day but did not improve.

A medical team from the National Heart Centre Singapore arrived with an extracorporeal membrane oxygenation (ECMO) machine at 11.50pm to support Mr Razib's heart function and successfully inserted it.

Mr Razib was taken from Khoo Teck Puat Hospital to National Heart Centre Singapore at about 1.25am, but on the way, the ECMO machine began beeping, which indicated that the battery charge was low.

Medical staff tried to plug the machine's power line into the socket in the ambulance, but there was no power supply and the ECMO machine could not be charged.


The battery went flat just as the vehicle arrived at Singapore General Hospital and Mr Razib was being transferred out at about 1.40am.

His pulse was present and his condition remained stable at the time, and the ambulance driver began unloading his stretcher by pulling it out from the ambulance.

However, the collapsible wheels of the stretcher failed to deploy, and the head portion of the stretcher fell to the ground while Mr Razib remained firmly secured on it.

His head did not directly strike the ground, and he was transferred to the critical care area. For about five minutes during this time, he was unsupported by the ECMO machine until it was powered up again at the critical care area, and he was transferred to the cardiothoracic surgery intensive care unit at about 2.15am.

He was assessed at regular intervals and observed to have fixed and dilated pupils at about 7.30am, suggesting an underlying neurological issue.

An urgent CT scan showed bleeding in his brain, with evidence of significant swelling and damage. It was expected to deteriorate and medical staff discussed terminating his ECMO support with his family. The support was ceased at 11.15am on Jun 21, 2018, and Mr Razib died within the hour.

An autopsy found that an acute heart attack and acute subdural haemorrhage, or bleeding in his brain, had caused his death.

Independent medical experts appointed to assist in the case found that the ECMO machine's failure was a near-miss event which did not cause or contribute to the cause of death.

However, suggestions were made for daily checks to be performed on the machine and to ensure its battery is fully charged before it is taken out on the road. A fully charged backup battery should also be brought along.


Investigations into the stretcher's collapse found that the ambulance driver had pulled the stretcher about a quarter of the way out of the ambulance before trying to lift it.

He discovered that the patient, who weighed about 85kg, was too heavy and asked for help.

The correct procedure was to pull it out a quarter of the way and lift it and pull it further up to about three-quarters of the way to allow the stretcher's legs to expand and click into place.

The ambulance driver said he gave the command to lift, and those assisting him had done so, but the stretcher's legs failed to extend. When the stretcher was dislodged, the head end fell to the ground with the driver still holding up the other end.

The porter from KTPH, who was to assist in unloading the stretcher under KTPH's guidelines, was unable to follow along in the ambulance as there was not enough space.

Even though SGH staff present had given some help, the stretcher was not unloaded appropriately and instead collapsed, said the coroner.

Maintenance reports showed that bi-annual inspections were performed on the stretcher and it had functioned as expected. Weekly maintenance checks on the ambulance and equipment were also found to be adequate.

The stretcher could withstand a load of up to 120kg without collapsing and had met operational expectations.


Dr John Thomas, a senior consultant neurosurgeon from Immanuel Centre for Neurosurgery, said that while he was unwilling to say that the fall was the sole cause of the bleeding in Mr Razib's head, it had contributed very significantly or 95 per cent to its development.

"Dr Thomas further explained that an 85kg man falling in a 45-degree arc from a height of about one metre would experience a fairly significant force even if he did not fall off the trolley," said the coroner. 

"Even a simple shake can tear something like a small vein without actually injuring the brain because the brain is connected to the skull by the veins."

Dr Thomas testified that it was the precipitation of the blood clot in Mr Razib's brain that "tipped everything over", but said Mr Razib had been managed within the appropriate standard of care after his fall at SGH.

Mr Razib's daughter expressed concerns during the coroner's inquiry, including that she was not informed of the risks of patient transfer, that the ECMO machine ran out of battery, that SGH did not immediately inform her of the fall and that the stretcher had malfunctioned.

The coroner found no basis to suspect foul play and said Mr Razib was very ill, and it is difficult to predict if he would have made good recovery. She conveyed her condolences to Mr Razib's family for their loss.

CNA has contacted the family's law firm on whether they are seeking any further legal action.

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