Finding into death of Polina Portnyagina
Deceased
POLINA PORTNYAGINA
Demographics
78y, female
Date of death
2015-09-10
Finding date
2017-06-29
Cause of death
Complications of a left tentorial meningioma
AI-generated summary
A 78-year-old woman with a meningioma detected incidentally on MRI in 2009 presented to hospital in 2015 with gait disturbance and falls. The tumour had grown significantly, causing hydrocephalus and mass effect. After appropriate informed consent discussions with neurosurgical staff using an interpreter, she elected to undergo surgery. She died suddenly on 10 September 2015 from complications of the meningioma (intratumoral haemorrhage and herniation) before surgery could be performed. The coroner found neurosurgical management appropriate but identified that the 2009 imaging report recommending no follow-up represented a missed opportunity for surveillance of tumour growth. Key lesson: incidental meningiomas warrant follow-up recommendations; radiologists should specify appropriate surveillance strategies rather than omitting follow-up advice.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Meningioma detected in 2009 with no follow-up recommendations
- Tumour growth over six years without surveillance imaging
- Intratumoral haemorrhage causing secondary mass effects and herniation
- Lack of radiology guidelines for reporting incidental meningiomas
Coroner's recommendations
- The Royal Australian and New Zealand College of Radiologists should develop guidelines requiring radiologists reporting incidental meningiomas to make specific recommendations to referring doctors regarding appropriate follow-up, such as surveillance imaging or neurosurgical review
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