Coroner's Finding: LAMBERT Judith Ann
Deceased
Judith Ann Lambert
Demographics
69y, female
Date of death
2010-02-16
Finding date
2013-06-13
Cause of death
left pontine haemorrhage with re-bleeding associated with hypertensive vascular disease
AI-generated summary
A 69-year-old woman died from left pontine haemorrhage with re-bleeding. On 2 February 2010, her GP referred her for a CT head scan after she reported two weeks of slurred speech. The scan on 11 February revealed a pontine mass (haemorrhage vs tumour). The radiologist Dr B. convey urgency to the GP Dr T. by phone, asking him to arrange neurosurgical review at Royal Adelaide Hospital. However, Dr T. failed to establish an effective contact plan. No phone calls were made on 11 February; 14 calls on 12 February were unsuccessful. A weekend intervened, and no welfare check was requested. The patient died on 16 February. Expert opinion indicated that urgent neurosurgical or neurological review, with aggressive blood pressure management, might have prevented re-bleeding. Dr T.'s failure to ensure contact within 48 hours and to arrange a welfare check represented a critical delay in management of an urgent neurological condition.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure of GP to establish effective contact plan after urgent imaging findings
- lack of welfare check despite urgent clinical situation
- delay in neurosurgical/neurological assessment
- patient left radiology department before scan review
- lack of documented urgency in written radiology report
- uncontrolled hypertension in setting of known brainstem haemorrhage
Coroner's recommendations
- Minister for Health should negotiate with Australian Medical Association, Royal Australian College of General Practitioners, or appropriate body to establish protocol: when urgent, unexpected or sinister findings are reported following medical imaging, the general practitioner must ensure the patient is notified within 48 hours (or less if clinically indicated); if patient cannot be notified, the GP must contact South Australian Ambulance Service or South Australia Police to conduct a welfare check and advise the patient to contact their GP
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