Mr M - Non-inquest findings

Contributing factors

• Delay in referral to Acute Stroke Unit upon emergency department presentation
• Rapidly fluctuating neurological symptoms leading to diagnostic uncertainty
• Initial emergency department assessment did not classify patient as a definite stroke candidate
• Stroke team not contacted immediately on admission despite presentation with acute neurological event
• Delay in stroke team review until 4:00 pm, beyond the 4.5-hour thrombolysis window
• Lack of formal process to ensure all potential stroke patients are discussed with stroke team at presentation
• ACA thrombus location made intervention difficult with reduced likelihood of success

Coroner's recommendations

1. Develop a formal process to ensure all actual or potential stroke patients are discussed with the Acute Stroke Team immediately on admission to the emergency department
2. Implement telephone discussion capability with the Acute Stroke Unit to determine lysis eligibility at time of presentation, prior to definitive imaging
3. Implement 'Code Stroke' initiative to streamline admission and management of stroke patients through the Emergency Department
4. Queensland Ambulance Service to participate in stroke management review process
5. Emergency Department and Acute Stroke Team to work collaboratively to improve timely assessment and early management
6. Prioritise notification of all actual or potential stroke presentations to the Acute Stroke Unit for advice at time of admission