Zimitat, Vivian Bexley
Deceased
Vivian Zimitat
Demographics
68y, male
Date of death
2004-07-24
Finding date
2006-07-28
Cause of death
pulmonary embolism secondary to immobilisation as a result of subdural haemorrhage following a fall
AI-generated summary
A 68-year-old man with cardiac history presented to Rockhampton Hospital after a fall with head trauma, found unconscious with alcohol intoxication. CT scanning revealed a right subdural haematoma and skull fracture. Contact with Brisbane neurology indicated no immediate surgery was needed. The patient deteriorated on day 4 with repeat imaging showing no change, but was not transferred due to claimed bed shortage (disputed). He died from pulmonary embolism secondary to immobilisation from the head injury. Expert evidence suggests transfer to neurosurgery would have been optimal, though survival was unlikely given his cardiopulmonary status. Key lessons include: maintaining complete records of specialist consultations and clinical decisions, and ensuring regional hospitals have access to neurosurgical expertise.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- subdural haematoma
- skull fracture
- immobilisation post-fall
- immobilisation during hospital stay
- deep vein thrombosis
- coronary artery atheroma
- secondary brain stem haemorrhages
- lack of local neurosurgical expertise
- disputed bed shortage preventing transfer
Coroner's recommendations
- Queensland Health ensure that proper and complete records be maintained in all specialist units of referral phone calls from regional hospitals or medical practitioners, including record of any opinion and/or decisions regarding transfer of the patient provided to the referring practitioner
- Queensland Health ensure that a neurological or neurosurgery service or access to such a service, be provided for the community of Rockhampton and district in whatever form is considered to be most appropriate following a prompt analysis of the needs of the region and that sufficient resources be provided for that purpose
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