Coronial
VIChospital

Finding into death of Wayne Ronald Watson

Deceased

Wayne Ronald Watson

Demographics

61y, male

Coroner

Coroner Ingrid Giles

Date of death

2023-12-30

Finding date

2026-03-13

Cause of death

Intracranial haemorrhage and myocardial infarct

AI-generated summary

A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin Hospital's cardiology team despite concerns about the head injury. He was taken directly to the cardiac catheterisation lab without ED assessment or CT brain imaging. A skull fracture and intracranial haemorrhage subsequently developed, likely exacerbated by anticoagulation. The coroner found that while the urgent cardiac intervention was appropriate, the head injury assessment was inadequately documented and not undertaken by staff trained in trauma management. A cardiology registrar without head injury expertise made the decision to proceed without neuroimaging based on undocumented clinical assessment. The case highlights the need for formal, documented head injury risk assessment by appropriately trained staff in complex presentations.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologyemergency medicineneurosurgeryintensive care

Error types

diagnosticcommunicationsystem

Drugs involved

heparinapixabanatenololatorvastatinbisoprololnicorandilsalbutamoltiotropium bromideglyceryl trinitrateaspirin

Clinical conditions

STEMI (ST elevation myocardial infarction)Ischaemic heart diseaseIschaemic cardiomyopathyPeripheral vascular diseaseCOPDIntracranial haemorrhageTraumatic brain injurySkull fractureSubdural haemorrhageSubarachnoid haemorrhageCerebral contusionHydrocephalusSubfalcine herniationUncal herniation

Procedures

ElectrocardiographyCoronary angiographyEndotracheal intubationCT brain imaging

Contributing factors

  • Fall with head strike and loss of consciousness at supermarket
  • Inadequate assessment of head injury by non-trauma trained staff
  • No documented physical or neurological examination of head
  • Decision not to perform CT brain imaging prior to cardiac intervention
  • Administration of anticoagulation (heparin) in setting of head injury with subsequent intracranial bleeding
  • Lack of formal documented risk assessment for head trauma
  • No ED clinician involvement in head injury assessment decision
  • Paramedics' concern about head injury not adequately escalated

Coroner's recommendations

  1. That Austin Health update its guidelines to include that all trauma head injuries, whether in the Emergency Department or an inpatient setting, be undertaken and documented by staff from a 'trauma specialty' (such as General Surgery, Neurosurgery, Emergency Medicine or the Intensive Care Unit) or who are otherwise trained in and familiar with Austin Health's Emergency Department Guideline on Suspected Head Injury in Adults.
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Source and disclaimer

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