Deceased
Reginald Desmond Benham
Demographics
85y, male
Coroner
Coroner Audrey Jamieson
Date of death
2019-08-25
Finding date
2023-07-14
Cause of death
Intracranial haemorrhage in the setting of a fall in a man with multiple comorbidities (palliated)
AI-generated summary
An 85-year-old man with multiple comorbidities suffered a fall at home and was transported to hospital with stroke symptoms. A CT brain scan revealed subtle subarachnoid haemorrhage (traumatic), but the VST consultant neurologist missed this finding and recommended thrombolysis. ED clinicians appropriately relied on this expert advice and commenced Alteplase at 10:45pm. The radiologist's report identifying haemorrhage became available at 10:42pm but was not communicated to treating clinicians until 11:23pm—a 40-minute delay. By then, approximately half the thrombolytic infusion had been administered. The thrombolysis caused massive intracranial haemorrhage and death. While preventability could not be established with certainty, critical opportunities to avoid inappropriate treatment were lost due to: (1) the neurologist's missed subtle CT finding, and (2) the radiologist's failure to telephone findings to the referring doctor in accordance with policy and standards. The coroner emphasised that checks and balances like direct communication of urgent findings are essential to prevent such errors.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
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