Coroner's Finding: Sylvia, Kate Marie
Deceased
Kate Marie Sylvia
Demographics
32y, female
Date of death
2021-12-06
Finding date
2026-08-12
Cause of death
cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage
AI-generated summary
Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. misdiagnosed migraine and discharged her despite her mother's concerns and atypical features. Kate deteriorated overnight and presented to The Queen Elizabeth Hospital with worsening symptoms. An MRI revealed a haemorrhage, initially misreported. Transfer to Royal Adelaide Hospital showed cerebral venous sinus thrombosis (CVST) with intracerebral haemorrhage. She received aggressive treatment including thrombectomy but died on 6 December 2021. The coroner found her death was preventable with appropriate imaging and hospital referral on 2 December, before disease progression. Key failures included premature diagnostic closure on migraine, inadequate neurological assessment, loss of critical information during handover, and failure to weight family concerns appropriately.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Premature diagnostic closure on migraine diagnosis at Sefton Park HASDS
- Failure to order imaging at Sefton Park despite concerning neurological features
- Loss of critical information (speech disturbance, sudden onset) during ambulance-to-clinic handover
- Inadequate weight given to collateral information and concerns raised by family
- Radiologist missing CVST diagnosis on initial MRI report and falsely reassuring recommendation
- Ambulance service delays in transfer to Royal Adelaide Hospital
Coroner's recommendations
- Paramedics to be reminded of the importance of not filtering information about patients; all findings may have relevance to clinicians making final diagnoses, even if they represent transient symptoms
- SA Health to expand HASDS exclusion criteria to cover headaches with different presentation than prior headaches, any migraine without formally recorded prior diagnosis, and any appearance of being seriously unwell
- All SA Health clinicians to be reminded that: prior diagnosis of migraine must be explored in detail to ensure genuine medical diagnosis; speech disturbance assessment requires baseline from family; collateral information about patient presentation is valuable particularly regarding neurological changes; transient symptoms reported in history should not be disregarded
- SA Health to develop program allowing family members in hospitals to escalate care where they consider concerns are not being taken seriously
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