Coroner's Finding: Brown, Paul Louis
Deceased
Paul Louis Brown
Demographics
64y, male
Date of death
2024-02-04
Finding date
2024-12-17
Cause of death
Subdural haematoma with mass effect following thrombolysis for acute myocardial infarction
AI-generated summary
A 64-year-old man with complex medical history including diabetes, mental illness, chronic alcohol misuse, and previous traumatic brain injury was admitted with diabetic ketoacidosis and acute kidney injury. He developed acute myocardial infarction (STEMI) and received thrombolysis after appropriate pre-treatment CT brain imaging showed no acute haemorrhage. He subsequently developed a catastrophic left-sided subdural haematoma causing his death. While the RCA report identified protocol non-adherence and failure to recognize previous intracranial haemorrhage as an absolute contraindication, independent expert review concluded the treatment was appropriate given the age of the previous injury (over three months prior), negative CT findings, clinical urgency, and treatment efficacy. The coroner found the death resulted from a known risk of thrombolysis rather than inappropriate management.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Procedures
Contributing factors
- diabetic ketoacidosis
- chronic kidney disease
- alcohol misuse
- previous traumatic brain injury with intracranial haemorrhage
- thrombolysis administration
Coroner's recommendations
- The Thrombolysis for STEMI Clinical Pathway may be appropriate for review to ensure alignment with literature
Full text
Related cases
Source and disclaimer
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —