Coroner's Finding: Woulleman-Jarvis, Anne Maree 2017 TASCD 188
Deceased
Anne Maree Woulleman-Jarvis
Demographics
62y, female
Date of death
2015-07-17
Finding date
2017-05-17
Cause of death
subacute subdural haematoma due to a closed head injury sustained in a fall from standing height
AI-generated summary
A 62-year-old woman on warfarin for a mechanical aortic valve sustained a head injury from a fall. A CT scan on day 5 post-injury identified a small extradural haematoma, but the radiologist (Dr J.) failed to report it, stating the scan was normal. The general practitioner accepted this normal report. Five days later, the patient presented to ED with worsening headaches unresponsive to opioids and nausea. Despite her anticoagulated status, recent head trauma, and concerning symptoms, the ED registrar (Dr P.) did not order a repeat CT scan, relying instead on the previous negative report. The patient was discharged home and died that night from the undiagnosed haematoma. The coroner found the death preventable through three failures: the radiologist's misreporting, the ED's failure to repeat imaging despite clinical red flags, and systemic ED understaffing that prevented proper senior review. The injury was treatable with 80-90% survival prospects if diagnosed on day 5, and remained treatable on day 11.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- failure to identify intracranial haematoma on CT scan performed 14 July 2015
- failure to order repeat CT brain scan in ED despite clinical indicators
- inadequate medical staffing in ED night shift
- cognitive error by junior doctor falsely reassured by previous normal scan report
- work pressure on senior registrar preventing proper clinical assessment
- anticoagulation with warfarin increasing risk of intracranial bleeding
- symptoms masked by analgesic administration
Coroner's recommendations
- Copy of findings to be provided to General Practice Tasmania and Royal Australian College of General Practitioners with recommendation to inform members of guidelines requiring prompt CT scanning of anticoagulated patients with head injury, even without loss of consciousness
- Address urgent medical staffing insufficiencies in ED - the coroner found that approval for additional staffing (5 registrars and 3-5 interns) was appropriate and necessary
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