Coroner's Finding: MAY Terrill Anthony

Contributing factors

• failure to align referral letter with presenting patient at ED triage
• CT angiogram report not communicated to ED clinical staff
• inadequate attempts to contact radiologist for results
• inadequate attempts to contact referring general practitioner
• ED consultant did not ask patient about contrast injection procedure
• no liaison between ED and Neurosurgery Department while patient present
• patient discharged without meaningful diagnosis
• neurosurgery outpatient appointment scheduled too far in future (9 April vs 3 April death)

Coroner's recommendations

1. Procedures within the RAH Emergency Department dealing with alignment of referral letters with presenting patients be regularly reviewed
2. The principal clinician of the Department of Neurosurgery ensure that clinicians advised of imminent arrival of patient with suspected subarachnoid haemorrhage liaise appropriately and timely with ED clinicians
3. ED clinicians refer cases of suspected subarachnoid haemorrhage to clinicians within the Department of Neurosurgery and/or Department of Radiology to identify appropriate diagnostic measures
4. General practitioners referring patients suspected of suffering subarachnoid haemorrhage be encouraged to verbally notify Emergency Departments of expected arrival of their patients
5. General practitioners who have referred patients suspected of suffering subarachnoid haemorrhage to hospitals carefully scrutinise discharge summaries to ensure all relevant diagnostic information has been taken into account and query discharge diagnoses if not satisfied they are adequate or accurate