Deceased
Michael John Russell and Leslie Robert Graham
Demographics
unknown
Date of death
2017-04-21
Finding date
2018-12-06
Cause of death
Michael Russell: intracranial haemorrhage complicating surgery for right cerebral artery occlusion complicating acute coronary syndrome due to bypass graft occlusion. Leslie Graham: left middle cerebral artery territory cerebral infarction
AI-generated summary
Two patients died following stroke interventions on 18 April 2017 at the Royal Adelaide Hospital. Michael Russell (60) died from intracranial haemorrhage following vessel perforation during thrombectomy for acute coronary syndrome; Leslie Graham (87) died from stroke progression after unsuccessful thrombectomy. The critical issue was that neither designated neurointerventional radiologist (Drs Taylor or Scroop) was available on the day, creating a crisis situation. Dr C., fortunately located nearby and listed on the CCINR register, was called in emergently. The coroner found that Dr S.'s arrangement to have Dr W. provide cover was inadequately communicated—Wilks understood he was only needed after hours, not for emergency stroke cases during business hours. The coroner criticised the autonomous, inadequately supervised INR service with only two permanent clinicians. Dr S. resisted nominating Dr C. due to personal antipathy despite his recognised competence. Systemic failures in recruitment and service planning meant no third INR was appointed despite clear need.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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Female·haemopericardium due to aortic dissection (all three cases)
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57y · Male·brainstem and cerebellar infarction due to vertebrobasilar artery thrombosis
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