Coronial
VIChospital

Finding into death of Kerri Louise Gunn

Deceased

Kerri Louise Gunn

Demographics

41y, female

Coroner

Coroner Heather Spooner

Date of death

2010-12-09

Finding date

2014-01-30

Cause of death

Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndrome (PRES)

AI-generated summary

Kerri Gunn, a 41-year-old woman five days post-caesarean delivery, presented to emergency with frontal headache, elevated blood pressure, proteinuria, abnormal liver function and lower limb oedema. She was admitted under general physician Dr Singh after ED assessment by Dr McKenzie. A CT brain performed that evening was reported as normal. Despite clinical concern for cerebral venous thrombosis documented on the request form, further investigation with MRI was not pursued as Mrs Gunn improved symptomatically. She collapsed four days later with massive intracerebral haemorrhage secondary to posterior reversible encephalopathy syndrome (PRES). The coroner found that further radiology, particularly MRI, should probably have been ordered when the CT was discovered to have been performed without contrast. PRES was extremely rare and difficult to diagnose clinically. While earlier recognition might theoretically have allowed treatment with antihypertensive therapy, medical evidence suggests outcome may not have changed given the high risk of haemorrhage.

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

Specialties

emergency medicinegeneral medicineneurologyneurosurgeryobstetricsintensive careradiology

Error types

diagnosticdelaycommunication

Drugs involved

paracetamolaspirinnifedipine

Clinical conditions

posterior reversible encephalopathy syndrome (PRES)cerebral venous thrombosishypertensionproteinuriaintracerebral haemorrhagesubarachnoid haemorrhagecerebral infarctionbrain oedemapost-partum complications

Procedures

CT brain imagingMRI imagingcraniectomyintracranial pressure monitoringmechanical ventilationfour-vessel angiogram

Contributing factors

  • Undiagnosed PRES in post-partum period
  • Failure to recognize constellation of symptoms suggestive of PRES (headache, hypertension, proteinuria, abnormal liver function, oedema)
  • CT brain performed without contrast despite clinical suspicion of cerebral venous thrombosis
  • Failure to pursue further neuroimaging (MRI) when initial CT reported as normal
  • Subtle subarachnoid haemorrhage on initial CT not identified in radiologist's report
  • Lack of continuity of care with obstetrician after discharge
  • Reassurance from apparent clinical improvement may have led to under-investigation
  • MRI not ordered despite indication and availability

Coroner's recommendations

  1. Recognition that PRES is an extremely difficult diagnosis to make clinically and may not be on treating clinicians' radar even in post-partum presentations
  2. Awareness of the constellation of post-partum symptoms (headache, hypertension, proteinuria, abnormal liver function, oedema) as potentially indicative of serious underlying conditions
  3. When CT brain performed without planned contrast in context of clinical suspicion of venous sinus thrombosis, further neuroimaging should be pursued
  4. Improved communication and continuity between discharging obstetrician and receiving acute care teams
  5. Clinicians should review available nursing notes and documented observations in addition to direct patient assessment to obtain complete clinical picture
  6. Consultation with neurology and obstetric specialists should be considered in post-partum presentations with unusual neurological symptoms
Full text
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