Deceased
Michael Peysack
Demographics
69y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2007-09-01
Finding date
2011-02-25
Cause of death
Head injury post-collapse secondary to ventricular tachycardia due to ischaemic cardiomyopathy
AI-generated summary
Mr Peysack, a 69-year-old with complex cardiac disease on Warfarin, collapsed at work with witnessed loss of consciousness and occipital laceration. Despite meeting criteria for urgent head CT imaging (age >65, head injury, loss of consciousness, anticoagulation), this was not performed in the Emergency Department due to failure to recognize and act upon the combination of risk factors. Information about the head injury was progressively omitted through verbal handovers and specialist compartmentalization focused on cardiac issues. He deteriorated rapidly on the ward 36 hours later with intracranial haemorrhage requiring emergency craniotomy. Expert evidence indicates early CT imaging would likely have identified subdural haematoma amenable to treatment, and with stable cardiac status he would probably have survived neurosurgical intervention. The death was preventable and highlights critical gaps in holistic assessment, reliance on incomplete verbal handovers, and failure to consult written medical records.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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