Finding into death of Mr V

Contributing factors

• Misdiagnosis of stroke as Bell's palsy on initial presentation
• Cognitive errors including premature closure and confirmation bias
• Inadequate imaging (non-contrast CT brain instead of CT perfusion)
• Failure of communication between diagnostic imaging and emergency department
• Lack of code stroke activation despite clinical presentation suggestive of stroke
• Three-day delay in diagnosis resulting in increased clot burden
• Arterial perforation during endovascular clot retrieval procedure
• Inability to control bleeding during procedure

Coroner's recommendations

1. Monash Health should consider whether their process of ensuring patients receive the right imaging scan can be made more reliable by minimizing work conditions that increase chances of error (such as addressing access block and rapid assessments in waiting room)
2. Monash Health should maximize work conditions which prevent predictable errors from reaching patients by requiring imaging requests to be vetted and approved by the radiology registrar rather than the Medical Imaging Technician, as the registrar has greater understanding of the clinical question and greater authority in discussions with medical staff