Finding into death of Keith Walter Sharp

63y · Male·Cerebral infarction complicating vertebral artery dissection following motor vehicle collision

Keith Walter Sharp, 63, sustained a motor vehicle collision causing vertebral artery dissection and subsequent cerebral infarction. At Albury Base Hospital, initial CT imaging at 10:44am identified significant cervical spine injuries, but critical imaging results (MRI and CT angiogram) were delayed approximately 4.5 hours. The patient deteriorated acutely around 5:15pm during further imaging. While early transfer to Royal Melbourne Hospital for possible interventional radiology might have offered limited benefit given stroke timing and logistics, systemic failures were identified: poor documentation, inadequate senior supervision, delayed imaging ordering, lack of awareness by the shift leader of critical results, and gaps in trauma referral pathways. The coroner noted the internal incident review was superficial and failed to explore underlying systemic causes or identify all contributing factors. Preventability remains uncertain given the rarity of bilateral vertebral artery injuries and the narrow therapeutic window.