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. Report an inaccuracy.
Specialties
emergency medicinecardiologyneurosurgery
Error types
diagnosticprocedural
Drugs involved
paracetamolanticoagulant medication
Clinical conditions
acute subdural haematomaclosed head injurysubarachnoid haemorrhagesyncope
Procedures
CT scanelectrocardiogram
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
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.