Coroner's Finding: RA
Deceased
RA
Demographics
17y, male
Date of death
2020-05-07
Finding date
2021-06-07
Cause of death
massive head injury sustained in a fall from height (approximately 3.5 metres through a shade sail onto concrete)
AI-generated summary
A 17-year-old male died from massive head injury sustained in a fall from approximately 3.5 metres through a shade sail at a primary school. He landed on concrete at 10:30 pm after the sail tore under his weight while jumping. Friends transported him to North West Regional Hospital (giving a false history of basketball injury) where CT imaging revealed significant intracranial bleeding. He was transferred by air ambulance to Royal Hobart Hospital for emergency hemicraniectomy but the injury was unsurvivable and he was declared brain-dead. Medical care at both hospitals and transfer were appropriate and timely. The coroner noted that friends should have called an ambulance rather than self-transporting, and that providing accurate injury history to medical staff is essential, though the false history did not affect the outcome in this case.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- fall from height of approximately 3.5 metres
- shade sail failure under weight during jumping activity
- delay in calling ambulance - friends transported patient themselves
- false history provided to medical staff at initial presentation (basketball injury rather than fall from roof)
Coroner's recommendations
- Friends and bystanders should call an ambulance rather than self-transporting injured persons to hospital
- Medical staff must have accurate history upon hospital admission as it is essential for appropriate clinical management
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