Coroner's Finding: Mr M
Deceased
Mr M
Demographics
41y, male
Date of death
2012-09-12
Finding date
2018-01-23
Cause of death
large volume thrombotic stroke within the distribution of the right posterior cerebral artery and posterior inferior cerebellar artery with basilar artery thrombus
AI-generated summary
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange urgent transfer to the Stroke Unit at Royal Hobart Hospital. Instead, an MRI was delayed 4 days. When the MRI eventually revealed basilar artery thrombosis with extensive infarction on 10 September afternoon, the LGH radiology department failed to contact NWRH clinicians, and NWRH staff were unaware they could access results via PACS system. This 21-hour delay in receiving the MRI result, combined with the initial diagnostic error, meant transfer occurred too late. Had the patient been transferred on 7 September with prompt diagnosis, anticoagulation and neurovascular intervention offered real prospects of functional recovery.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- misdiagnosis of encephalitis instead of posterior circulation stroke
- failure to transfer to stroke unit when diagnosis should have been made on 7 September
- delay in obtaining urgent MRI scan (4 days)
- failure of radiology to communicate MRI findings to referring clinicians
- clinicians unaware of PACS system for accessing imaging results
- 21-hour delay in medical staff becoming aware of critical MRI findings
- atherosclerotic and hypertensive cardiovascular disease
- emphysema
- long-term smoking
Coroner's recommendations
- Nursing and medical staff to be educated regarding access to radiology results online with posters and online links for using PACS sent to all clinical leaders and nursing unit managers at NWRH
- ICU and radiology consultants to discuss MRI requests and results conveyed via telephone and fax immediately following procedure
- LGH radiology to assess scans and discuss results with treating consultant immediately to determine whether patient should be transferred to another hospital prior to departing radiology department
- Improvement in collaboration between Medical and ICU teams at NWRH to promote patient outcomes through monthly meetings
- All HDU patients at NWRH to have documented review each day as minimum standard of care
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