Deceased
John Laurenson
Demographics
47y, male
Coroner
Decision ofDeputy State Coroner Ryan
Date of death
2017-06-20
Finding date
2021-03-31
Cause of death
sequelae of ruptured brain aneurysm
AI-generated summary
John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison cell. He had multiple intracranial aneurysms identified in 2015-2016, including a 23mm aneurysm. Multiple opportunities to provide earlier specialist treatment were missed: Canberra Hospital failed to arrange follow-up after discovering the aneurysms; during his first imprisonment (May-September 2016), Justice Health did not initiate specialist referral despite having medical records; during his second imprisonment, a GP incorrectly referred him to vascular rather than neurosurgery, delaying urgent neurosurgical consultation by four months; the MDT at Prince of Wales Hospital lacked critical information about aneurysm growth (2015 scans unavailable) that would have triggered urgent treatment. Expert evidence indicated earlier intervention may have prevented the fatal haemorrhage. Systemic failures in medical record management, specialist referral processes, and information gathering contributed to delays in diagnosis and treatment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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