Coroner's Finding: HAWKE Anne Elizabeth
Deceased
Anne Elizabeth Hawke
Demographics
33y, female
Date of death
2000-08-30
Finding date
2003-12-19
Cause of death
Raised intracranial pressure secondary to thrombosis of the superior sagittal, transverse and sigmoid sinuses and cortical veins and massive venous infarction of the left posterior frontal lobe
AI-generated summary
A 33-year-old woman presented with acute neurological symptoms (headaches, weakness, slurred speech, seizures) on 26 August 2000. Initial CT imaging showed focal haemorrhage with oedema; repeat CT after 50 minutes showed significant progression with increased mass effect. However, the diagnosis of cerebral venous thrombosis (CVT) was not pursued despite radiologists recommending MRI. Poor communication between radiologists and neurosurgeons meant the on-call neurosurgeon was given an incomplete clinical picture, leading to conservative management over the weekend. MRI and angiography were delayed until Tuesday 29 August. The patient died on 30 August from raised intracranial pressure secondary to sagittal sinus thrombosis and venous infarction. Early diagnosis and heparin therapy could have reduced mortality from 69% to 15%. Clinicians failed to vigorously pursue the diagnosis, no emergency neurological input was sought, and poor interdepartmental communication prevented timely investigation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to vigorously pursue diagnosis during weekend of 26-27 August
- Non-involvement of experienced neurologist
- Poor communication between radiologists and neurosurgeons
- Failure of senior registrar to read written radiology report and appreciate significance of second CT scan
- Inadequate briefing of on-call neurosurgeon regarding clinical severity
- Delayed involvement of neurosurgical consultant
- Delayed MRI and angiography investigation
- Lack of urgency and general disorganisation in patient management
- Delayed commencement of anticoagulation therapy
Coroner's recommendations
- Flinders Medical Centre should review clinical practices and procedures to ensure improved communication between clinicians and between clinicians and radiologists, appropriate specialty involvement in treatment, and adequate consultant briefing before treatment decisions
- Flinders Medical Centre Radiology Department should ensure written reports are maintained in original state with any changes made only by way of addendum rather than rewriting the original report
- Medical practitioners prescribing oral contraceptive pill should take careful personal and family history for thrombo-embolism. If relevant history exists, patient should be screened for Factor V Leiden. If positive, patient should be advised of substantially increased risk of thrombo-embolism
Full text
Related cases
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —