Finding into death of Mark James O'Brien

Contributing factors

• Failure to identify subtle posterior cortical left femoral fracture on initial imaging (17 June 2019)
• Lack of clinical context in radiological referral (recent seizure and pain not communicated)
• Continued mobilisation and rehabilitation on undiagnosed fractured limb for 9 days
• Difficult clinical assessment due to impaired cognition and communication difficulties
• Absence of communication aid during hospital admission
• Complex medical presentation with seizures, dementia, and delirium obscuring diagnosis

Coroner's recommendations

1. Monash Imaging and Monash Health to augment annual orientation program for new medical staff to reinforce importance of ensuring complete medical information is contained in procedure requests, including patient's current presentation and clinical indicators for referral
2. Mr O'Brien's case to be referenced as an example in the augmented orientation program
3. Monash Imaging to continue using Mr O'Brien's case as a teaching and peer learning example regarding abnormalities at the periphery of radiographs and rare fractures in education sessions and quarterly consultant council meetings
4. Related teaching vignette to be prepared and distributed to all diagnostic imaging medical staff