Finding into death of Mr V
Demographics
73y, male
Date of death
2020-09-09
Finding date
2023-05-24
Cause of death
Combined effects of cerebrovascular accident and subsequent iatrogenic related intracerebral haemorrhage and subarachnoid haemorrhage
AI-generated summary
A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequate for stroke evaluation) was performed instead of CT perfusion. He was discharged with prednisolone. Three days later, he returned with worsening symptoms and was found to have a left internal carotid artery occlusion with large infarct. Emergency endovascular clot retrieval was performed but the artery was perforated, causing iatrogenic intracranial haemorrhage from which he died. Earlier stroke recognition would have enabled timely intervention with better procedural outcomes and reduced complication risk, though death was ultimately due to a recognised procedure complication.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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
- 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)
- 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
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