Inquest into the death of Brendan BURNS
Deceased
Brendan Burns
Demographics
24y, male
Date of death
2009-01-27
Finding date
2014-05-09
Cause of death
acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of the brain
AI-generated summary
Brendan Burns, 24, died from acute hydrocephalus caused by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over one week. On 25 January 2009, Dr H. at Hay Hospital, concerned about possible space-occupying lesion, arranged urgent transfer to Griffith Base Hospital for CT scan. However, Drs Hall and Wark misdiagnosed alcohol withdrawal despite weak evidence (patient abstinent 2 weeks, minimal withdrawal screen), and discharged him without imaging. Brendan suffered catastrophic brain herniation overnight and died in Sydney the next day. The coroner found the failure to order CT scan despite clear red flags—referring doctor's explicit concerns, concerning history, and significant neurological deficits—was a serious and inexplicable clinical lapse. Early diagnosis and surgical drainage could potentially have altered outcome. Key lessons: recognise diagnostic anchoring bias, obtain complete patient history, appropriately weight referral information and clinical red flags, and ensure diagnostic uncertainty prompts investigation of serious pathology.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to order CT brain scan at Griffith Base Hospital despite clear indication
- misdiagnosis of alcohol withdrawal as primary diagnosis
- incomplete history taking by Dr W.
- insufficient weight given to referral information and concerns of referring physician
- failure to recognise cluster of serious neurological signs and symptoms
- failure to admit patient for overnight observation
- failure to arrange emergency neurosurgical retrieval from Griffith Hospital
- diagnostic anchoring bias fixation on alcohol withdrawal
- cognitive fatigue and heuristic-based decision-making affecting clinical judgment
Coroner's recommendations
- Consider implementing a scheme for organising regular short-form neurosurgical skills training for general surgeons operating in NSW regional centres
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