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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. 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
  • frailty of age
  • hypertension
Full text

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