Missed throat scan finding led to Brisbane man Kyle Gallagher’s preventable death, coronial inquest finds

A young man who survived a devastating motorbike crash died weeks later after doctors failed to recognise a life-threatening injury already visible on a scan, a coronial inquest has found.

Kyle Gallagher, 22, had suffered significant injuries in a crash on June 17, 2023, at Boundary Rd in Narangba, about 40 minutes north of Brisbane, after losing control of a motorcycle and sliding into oncoming traffic, where he collided with a car.

He spent weeks moving in and out of the Royal Brisbane and Women’s Hospital as he recovered from a brain injury and multiple physical traumas.

Twelve days after the accident, he discharged himself against medical advice, only to return later the same day in pain and be readmitted.

Days later, he again left hospital before re-presenting on July 6, telling doctors he was in pain and unable to cope at home.

“Kyle didn’t understand that he’d had an accident,” his stepmother Tegan Samorowski said at that time.

“Sometimes he’d move, feel pain and ask, ‘Dad why am I so sore?’”

Eventually, the young roofer was admitted to the Surgical, Treatment and Rehabilitation Service (STARS) on July 10, after first being sent home due to a lack of beds, with his recovery appearing on track and his family expecting a full recovery.

But in the days before his death, he repeatedly complained of throat pain and difficulty breathing, at times becoming distressed and telling staff he felt like he could not breathe.

Concerned about his care, his family invoked Ryan’s Rule in an effort to take control of medical decisions but were told he was considered to have capacity.

His symptoms prompted further investigation, including a CT scan of his neck on July 13.

A coronial inquest into his death has now found critical warning signs were missed in the final 24 hours of his life.

A specialist radiologist described his larynx as “grossly abnormal”, identifying significant airway narrowing and raising concerns about infection and structural damage.

The abnormality was not subtle, and although the radiologist contacted clinicians directly to flag concern, the treating ear, nose and throat (ENT) team did not recognise the severity.

“The ENT clinicians did not identify the serious compromise of Kyle’s airway,” the coroner found on Tuesday.

Instead, clinicians were reassured his airway was stable, meaning no urgent intervention was undertaken despite evidence it had narrowed to a critical degree.

If the scan had been properly understood and acted on, Gallagher would have been transferred for urgent treatment to secure his airway, potentially through intubation or a tracheostomy.

“Had an appropriate ENT assessment have been undertaken, on balance, Kyle would not have died,” the coroner found.

He remained in a rehabilitation setting overnight, where staff monitored him.

Throughout the evening, Gallagher became increasingly agitated, repeatedly calling for help and expressing fear he could not breathe, sending messages to his family pleading for help.

“I need something to help me breathe. They’re not giving me anything and I won’t make it longer,” he texted his father.

Loved ones later told 7NEWS they believe he knew he was dying.

Staff attributed his symptoms to anxiety and his brain injury, and while he was closely observed, the underlying cause of his deterioration remained unrecognised.

The inquest found nursing staff checked on him frequently and acted appropriately based on the information they had, but Gallagher’s condition had worsened but the early hours of July 14.

His mother, Christina Dargusch, woke to a missed call from her son.

He was later found unresponsive and not breathing. Despite resuscitation efforts, he could not be saved.

Gallagher died from airway obstruction caused by a severe laryngeal condition linked to his earlier injuries, which led to hypoxia (a lack of oxygen), despite the obstruction having been identified on a CT scan the day before.

The coroner found the ENT assessment on July 13 was not appropriate and did not adequately account for the scan findings, the radiologist’s concerns, or Gallagher’s worsening symptoms.

The inquest also highlighted broader issues around communication, escalation and the use of specialist imaging, particularly in complex cases involving junior doctors and busy clinical settings.

In this case, a breakdown in communication between junior and senior doctors contributed to the failure to recognise the seriousness of the scan, the findings said.

Recommendations were made to strengthen escalation pathways, improve how radiology findings are incorporated into decision-making, and ensure airway risks are identified and managed earlier.