Coroner's Finding: Lumley, Barry Alyn
Deceased
Barry Alyn Lumley
Demographics
81y, male
Date of death
2019-08-12
Finding date
2021-05-24
Cause of death
acute subdural haematoma
AI-generated summary
An 81-year-old man suffered a witnessed fall at a shopping centre with head strike to the right parietal region. He presented to the ED with a small haematoma and confusion. The ED team concluded he had a cardiac cause for syncope based on chest pain, referred him for cardiology, and did not perform a head CT scan despite clear evidence of head injury. The Canadian CT Head Rule, which mandates imaging for patients over 65 with head strike, was apparently considered but not executed. Two days later, he deteriorated with headache and was found unresponsive. CT imaging revealed a massive acute subdural haematoma. He died shortly after. Early CT imaging following the initial head injury would very likely have detected the haematoma and permitted intervention, potentially preventing death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to perform head CT scan despite clear head injury and age >65
- diagnostic error: attribution of presentation to cardiac cause rather than head injury
- frailty of age
- hypertension
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