Deceased
Peter Roy Gillam
Demographics
44y, male
Date of death
2005-02-24
Finding date
2007-08-02
Cause of death
Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneurysm with subarachnoid haemorrhage
AI-generated summary
Peter Gillam, age 44, died from sepsis and pulmonary thromboemboli complicating a ruptured cerebral aneurysm with subarachnoid haemorrhage (SAH). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exclude SAH after acute severe headache and neck stiffness. At Modbury Hospital ED on 16 December, a staff member inappropriately told the family the facility was closed and suggested paying privately, leading them to leave without assessment. On 17 December, the patient returned; ED doctor Dr A.-Khalfa focused on reactive depression and discharged him after a brief medico discussion without CT scan, despite Dr H.'s letter specifically requesting SAH exclusion. The patient's resolved headache by day 2 was misinterpreted as excluding SAH. Early diagnosis and treatment would have provided >80% survival chance. Critical failures included: failure to obtain imaging despite explicit GP concern, inappropriate focus on psychiatric presentation, inadequate communication between junior clinician and registrar, and staff misinformation about after-hours services.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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