Coronial
VIChospital

Finding into death of John Alan Hemingway

Deceased

JOHN ALAN HEMINGWAY

Demographics

62y, male

Coroner

Coroner Kim M. W. Parkinson

Date of death

2009-09-14

Finding date

2011-10-06

Cause of death

Brain swelling associated with cerebral infarction; drainage acute on chronic subdural haemorrhage; head injury

AI-generated summary

John Hemingway, a 62-year-old man with cerebral palsy, hydrocephalus, and epilepsy, sustained a head injury when a vehicle rolled backward and struck him while he was in a wheelchair. The driver, an international student on an international licence, had failed to engage the handbrake and left the patient unattended behind the vehicle. Mr Hemingway was hospitalized with an acute subdural haemorrhage. On readmission for surgical drainage, he developed status epilepticus, suffered bilateral posterior cerebral artery infarction, and died. The coroner identified failures in vehicle safety procedures, driver training standards, and supervision of casual staff. Key preventability factors included unsafe unloading procedures, failure to engage the handbrake, and lack of Victorian licence requirements for employed drivers.

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Specialties

neurosurgerygeneral medicineintensive care

Error types

proceduralsystemcommunication

Clinical conditions

subdural haemorrhagecerebral infarctionstatus epilepticushead injurycerebral palsyhydrocephalusepilepsy

Procedures

burr hole drainage

Contributing factors

  • Failure to engage vehicle handbrake
  • Unsafe unloading procedures leaving patient unattended in wheelchair behind vehicle
  • International driver not licensed in Victoria with no local road rules testing
  • Inadequate supervision of casual employee
  • Vehicle parked on slight incline

Coroner's recommendations

  1. That the licensing regulator VicRoads review whether a person not holding a Victorian Drivers Licence ought be entitled to be employed to drive a motor vehicle and convey passengers, relying solely on country of origin licence and international drivers licence, and without meeting local licensing testing standards
Full text

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