Coroner's Finding: Mr M

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

1. 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
2. ICU and radiology consultants to discuss MRI requests and results conveyed via telephone and fax immediately following procedure
3. 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
4. Improvement in collaboration between Medical and ICU teams at NWRH to promote patient outcomes through monthly meetings
5. All HDU patients at NWRH to have documented review each day as minimum standard of care