Finding into death of Beatrix Dammers

Contributing factors

• Misdiagnosis of ischaemic stroke based on non-diagnostic CT imaging in absence of focal neurological signs
• Initiation of anticoagulation therapy (Clexane then heparin) for presumed ischaemic stroke without adequate clinical or radiological evidence
• Failure to cease anticoagulation and arrange urgent rescanning when patient deteriorated neurologically at 10:30pm with new visual field defect
• Escalation of heparin dose following new neurological deficit rather than investigation and cessation of therapy
• Delay in transfer to specialist neurosurgical facility; emergency neurosurgery could not be performed at Knox Private Hospital due to unavailable neurosurgical nursing staff
• Inadequate clinical correlation between CT findings and patient's clinical presentation; excessive reliance on imaging

Coroner's recommendations

1. Clinicians should ensure CT findings are correlated with patient's clinical signs and symptoms and should not be relied upon in isolation for neurological diagnosis
2. Hospitals should ensure protocols are established for rapid assessment and imaging of patients presenting with acute neurological symptoms
3. Hospitals should ensure appropriate staff are available 24/7 for emergency neurosurgical procedures
4. When patients deteriorate whilst on anticoagulation therapy, clinicians should immediately cease the therapy and arrange urgent rescanning rather than escalating the dose