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Coroner's Finding: Masters, Shane Anthony

Deceased

Shane Anthony Masters

Demographics

40y, male

Date of death

2021-02-11

Finding date

2022-05-18

Cause of death

Sudden Unexpected Death in Epilepsy (SUDEP) resulting from post-traumatic brain injury sustained on 19 May 2008

AI-generated summary

Shane Masters died from Sudden Unexpected Death in Epilepsy (SUDEP) 12 years after sustaining a severe traumatic brain injury at work. On 19 May 2008, a hydraulic jack dislodged while repairing a fully loaded truck in a workshop pit, striking him and causing multiple skull fractures, haemorrhage, and brain contusions requiring neurosurgery. He developed post-traumatic epilepsy with persistent seizures despite medication compliance challenges due to memory impairment. On 11 February 2021, he suffered a fatal seizure at home. The workplace incident was preventable: the trailer should have been unloaded before repair, the jack lacked proper stabilisation with friction material, there were no documented safety procedures, and the company had failed to comply with statutory risk assessment obligations. WorkSafe issued a compliance notice which was subsequently satisfied.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

neurosurgeryrehabilitation medicineneurologygeneral practiceoccupational and environmental health

Error types

systemprocedural

Clinical conditions

post-traumatic epilepsytraumatic brain injurysubarachnoid haemorrhagesubdural haematomabrain contusionscerebral oedemasudden unexpected death in epilepsyacquired brain injury

Procedures

neurosurgerymechanical ventilation/intubationintraosseous catheter insertioncardiopulmonary resuscitation

Contributing factors

  • Post-traumatic epilepsy secondary to severe brain injury with scarring
  • Low seizure threshold requiring strict medication adherence
  • Memory impairment causing occasional missed medication doses
  • Two sequential seizures within hours on 11 February 2021
  • Seizure-related respiratory compromise and asystole
Full text

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