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Coroner's Finding: Leary, Kane

Deceased

Kane Mathew Leary

Demographics

17y, male

Date of death

2021-05-30

Finding date

2024-03-27

Cause of death

stroke (left middle cerebral artery infarction) following motorbike collision due to dissection of left internal carotid artery

AI-generated summary

Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on initial CT scans (27 May 2021). Although appropriate angiographic imaging was ordered by the emergency physician, the radiologist failed to identify a subtle occlusion at the terminal carotid vessel on over 6,500 images—missed despite being visible to experienced specialists. Early neurosurgical consultation would likely have identified the injury before irreversible brain damage occurred. Had the dissection been detected within 6-8 hours, endovascular clot retrieval could have offered salvage. Key failures: (1) radiologist interpretation error on original scans; (2) absence of neurosurgical team consultation despite head trauma concern and GCS drop. Enhanced trauma protocols, quality-controlled radiological services, and lower thresholds for specialist consultation in polytrauma with head injury are essential preventive measures.

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

Specialties

emergency medicineneurosurgeryradiologyorthopaedic surgeryintensive careanaesthesia

Error types

diagnosticcommunicationsystemdelay

Drugs involved

morphineketamine

Clinical conditions

carotid artery dissectionacute ischaemic strokeblunt cerebrovascular injurypolytraumabrain infarctionbrain swelling

Procedures

CT trauma series scanCT angiogramendotracheal intubationorthopaedic surgery

Contributing factors

  • failure to identify left internal carotid artery dissection on initial CT scans
  • absence of early neurosurgical team consultation
  • radiologist interpretation error
  • delay in specialist review of imaging
  • after-hours external radiology service limitations
  • incomplete trauma protocol for head injury assessment

Coroner's recommendations

  1. Update the trauma protocol at Launceston General Hospital to include direction on when clinicians must consult the neurosurgical team in Hobart, with guidelines stressing that consultation should occur even with minor suspicion of head trauma
  2. Implement all recommendations from the Root Cause Analysis report that have not yet been implemented
  3. Implement a diagnostic imaging flowchart for patients with severe trauma to prompt consideration of CT angiography of the neck
  4. Tasmanian Health Service should consider and explore employment of additional radiologists during normal hours and in-house radiologists after hours to improve quality control, reduce reporting delays, and enable direct communication between clinicians and radiologists
Full text

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