QLDhospital

Non-inquest findings into the death of Ms B

Deceased

Ms B

Demographics

35y, female

Coroner

Zerner

Date of death

2024-03-30

Finding date

2026-03-06

Cause of death

Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebrobasilar thrombosis due to vertebral artery dissection

AI-generated summary

A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnosis of mental disorder. She deteriorated at home and presented to a tertiary hospital where she suffered cardiac arrest from basilar/vertebral artery thrombosis due to vertebral artery dissection. The coroner found the initial assessment inadequate: the senior medical officer failed to recognise classic posterior circulation stroke signs documented by paramedics, did not contact a stroke specialist, and inappropriately attributed symptoms to mental health issues. While early diagnosis may not have changed the outcome given rural location and transfer times, the discharge was inappropriate and represented a diagnostic failure due to anchoring bias and attribution error.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinegeneral practiceneurologyradiology

Error types

diagnosticcommunication

Clinical conditions

vertebral artery dissectionbasilar/vertebral artery thrombosisposterior circulation strokehypoxic-ischaemic encephalopathycardiorespiratory arrest

Procedures

CT head scancardiopulmonary resuscitation

Contributing factors

failure to recognise posterior circulation stroke signs
failure to contact stroke specialist for consultation
inappropriate attribution of neurological symptoms to mental health disorder
anchoring bias on patient's psychiatric history
inadequate focused neurological examination
inappropriate discharge despite ongoing severe symptoms
non-contrast CT brain scan inadequate for posterior circulation stroke diagnosis
lack of knowledge regarding stroke assessment in senior medical officer
variable training and credentialling of locum senior medical officers

Coroner's recommendations

Publish coronial findings on Coroners Court of Queensland website as educational material for clinicians regarding early diagnosis of stroke in young patients
Provide findings to Clinical Excellence Queensland for use as teaching example for junior doctors on importance of early stroke diagnosis
Provide findings to Office of Health Ombudsman regarding the SMO's competency in emergency medicine practice
Consider implementation of specialist credentialling requirements for emergency department senior medical officers at rural hospitals
Improve training and orientation protocols for locum and relieving medical officers regarding stroke assessment and access to specialist consultation
Develop protocols for early consultation with stroke specialists for patients with suspected posterior circulation stroke in rural settings

Full text

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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.