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 Bau convey urgency to the GP Dr Tan by phone, asking him to arrange neurosurgical review at Royal Adelaide Hospital. However, Dr Tan 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 Tan'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.
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Specialties
Error types
Clinical conditions
Procedures
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