A man suffered severe brain damage in a Sydney hospital and later died after air bubbles entered his bloodstream through a tube that was unnecessarily left in him for six hours, an inquest has heard.
Phillip Ibrahim, 39, suffered an air embolism in 2014 a day before he was due to be discharged from the intensive care unit of Concord Hospital, where he'd been receiving treatment for pneumonia.
An inquest at Glebe Coroner's Court is examining the management of Mr Ibrahim on October 27 and 28.
Mr Ibrahim, a fitness fanatic who owned an organic meal-delivery business, presented to the hospital on October 17 with bronchopneumonia, counsel assisting the coroner Maria Gerace told the court on Tuesday.
Doctors ordered a central venous access device - or line - be inserted into his right neck vein "to facilitate the administration of medication to Phillip and monitoring of his central venous pressure," Ms Gerace said.
By October 28, "invasive" support to help him breathe had been removed, and he had remained stable overnight.
At midday, a doctor ordered his CVAD also be removed, but this didn't occur.
Over the next few hours, he was happy and saw visiting family including his wife and children, Ms Gerace said.
But at 6.10pm, while sitting in a recliner, chatting and eating food brought in by his brother, Peter, Mr Ibrahim made a "sudden coughing sound" and collapsed.
Dr Nagesh Jadav, then-senior registrar on the ward, raced to Mr Ibrahim's side but found he was showing "significant neurological compromise".
"Phillip was not responding to any commands and was very rigid in all his limbs ... he had his eyes rolling upwards," Dr Jadav told the inquest.
A registered nurse noticed a "chook's foot" - a multi-flow attachment - on Mr Ibrahim's CVAD was disconnected, uncapped and "open" to air, Ms Gerace said.
Dr Jadav said air embolism caused Mr Ibrahim's sudden deterioration, having ruled out a blood clot or a stroke.
Mr Ibrahim was transferred to Prince of Wales Hospital for hyperbaric treatment but had "signs of very severe brain damage" and his life support was turned off on October 30.
Outside court, Mohsen Ibrahim - flanked by his other son, Peter, and Phillip's wife, Leanne - said his son had been an "affable, personable and charismatic" young man.
"This preventable death has left a six-year-old boy and a two-year-old girl without the care, love, support or guidance of a father for the rest of their lives," he told reporters.
"Part of the coroner's role is to protect lives by bringing to the notice of relevant authorities any procedures, regulations (or) laws which could be changed to prevent similar deaths in the future.
"I hope this inquest achieves that objective."