Coronial
TAShospital

Coroner's Finding: de-identified OQ

Demographics

41y, female

Date of death

2023-07-20

Finding date

2025-04-29

Cause of death

frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm complicating subarachnoid haemorrhage due to ruptured saccular aneurysm

AI-generated summary

A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days with headache, neck stiffness, photosensitivity, vertigo, nausea, vomiting, and a syncopal episode. Critical failures occurred at the Royal Hobart Hospital ED on 18 July when staff rapidly accepted a migraine diagnosis without sufficiently considering subarachnoid haemorrhage or reviewing available ambulance notes from 15 July that documented concerning symptoms. A CT scan at this presentation would have revealed the haemorrhage. Earlier diagnosis and aneurysm securing via coiling or clipping may have prevented subsequent vasospasm complications and death. The coroner emphasised the importance of actively investigating life-threatening intracranial conditions in patients with relevant symptomatology.

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

Specialties

emergency medicineneurosurgerygeneral practiceparamedicineradiologyintensive care

Error types

diagnosticcommunicationsystem

Drugs involved

chlorpromazinesumatriptan

Clinical conditions

subarachnoid haemorrhagecerebral aneurysmcerebral vasospasmacute bilateral anterior cerebral artery infarctsmigraineheadachesyncope

Procedures

coiling procedure for aneurysm thrombosisCT scan of headinterventional radiology treatment for vasospasm

Contributing factors

  • delayed diagnosis of subarachnoid haemorrhage
  • failure to sufficiently consider life-threatening diagnoses in ED
  • failure to review available ambulance records documenting concerning symptoms
  • rapid acceptance of migraine diagnosis without adequate investigation
  • suboptimal blood pressure management post-operatively
  • communication and documentation issues regarding blood pressure management
  • patient's decision to decline CT scan and treatment on two occasions
  • patient presented to multiple treatment providers
  • patient underplayed symptoms when communicating with clinicians
  • vasospasm complication not detected early enough
Full text

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