SINGAPORE - A coroner's inquiry into Mr Razib Bahrom's death in 2018 has thrown up a series of potentially dangerous issues.
There were mishaps in his care after a heart attack, one of which likely precipitated his death.
Mr Razib was 55 years old when he felt chest pains on June 17, 2018, and it worsened during the day. At about 9pm, he went to Khoo Teck Puat Hospital, where he was diagnosed and treated immediately.
The doctors inserted two stents that night. They also gave him medication, but in spite of that, his heart function remained poor.
The team called the National Heart Centre Singapore (NHCS) for an extra-corporeal membrane oxygenation (Ecmo) machine - which pumps blood into an artificial lung that removes carbon dioxide and adds oxygen to the blood before returning it to the body.
A team from the Heart Centre arrived with the Ecmo machine at 11.50pm and Mr Razib was successfully put on its support.
All was fine up to that point. It was during the transfer of the patient from KTPH to the Singapore General Hospital (SGH) that things went wrong.
As Mr Razib was on the Ecmo, he was accompanied in the ambulance by medical staff from both NHCS and KTPH.
With so many people in the ambulance, the porter, who would normally help the driver to move the patient, had to be left behind.
On the way, the Ecmo started beeping, indicating that it was low on battery. The machine had been checked and the battery was full before it left the NHCS.
The ambulance has a power supply, so the team tried to plug the machine in. They asked the driver to turn on the power supply, but he didn't know where the switch was. He tried two switches but neither worked.
The coroner heard that the standalone power pack in the ambulance requires two switches - a master switch behind the driver's seat and a manual switch near the steering wheel.
KTPH has since modified its ambulances so that the battery power supply is turned on along with the ambulance engine.
The Ecmo machine ran out of battery power just as Mr Razib arrived at SGH and he was without the machine's support for five minutes.
Staff there were standing by with an extension cord.
In spite of five minutes without the machine, Mr Razib's condition remained stable.
The machine had been properly maintained, so the coroner said its failure "can be regarded as an unexpected electrical failure and should not be regarded as a lapse in care".
But she suggested that a full spare battery pack be carried in future.
On arrival at the hospital, the driver pulled the stretcher out a quarter of the way. He then needed to lift the stretcher up by 23cm before pulling it out further so that the legs would be deployed.
This is usually done with the help of the porter, who had been left behind. The driver found this difficult as Mr Razib weighed 85kg. He called for help and staff from SGH assisted.
But the legs of the trolley did not deploy and the end of the trolley, where Mr Razib's head was, dropped to the floor.
The driver said the ambulance bay was "chaotic" and he was unable to hear the sound of the legs clicking into place. He thought the trolley had been pulled out too fast, not giving the legs time to lock into place.
He was still holding one end when the other side dropped.
The coroner's report said CCTV footage showed that "the stretcher appeared to be pulled out steadily and the stretcher's collapse was sudden". Mr Razib had been properly strapped in, so his head did not hit the floor.
An independent medical expert, Dr John Thomas, a senior consultant neurosurgeon from Immanuel Centre for Neurosurgery, said that an 85kg man falling in a 45-degree arc from a height of about 1m would experience a fairly significant force even if he did not fall off the trolley.
Mr Razib was also on anti-platelet therapy for this heart problem which increases the risk of bleeding. Dr Thomas said the fall contributed significantly - as much as 95 per cent - to bleeding in the brain.
He added that a blood clot in the brain "tipped everything over", made the condition caused by the heart attack worse and was the cause of his death on June 21, 2018.
State Coroner Kamala Ponnampalam ruled that Mr Razib's death was an unfortunate medical misadventure.