Finding into death of George Diamond

18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting of martial arts activity

George Diamond, 18, died from acute-on-chronic subdural haemorrhage sustained during boxing sparring on 18 February 2019. He had suffered a head injury during sparring on 25 October 2018, presenting with headache, nausea and dizziness. Dr H. reviewed him on 31 October with ongoing symptoms but did not order a CT scan, which the coroner found would have been prudent. George presented to Frankston ED on 5 November with persistent headache and vomiting; Dr R. declined imaging, citing radiation risk concerns, a decision the coroner found should have been reconsidered. On 25 January 2019, Dr H. signed George's boxing medical clearance without reviewing prior medical records or the ED discharge summary, and inadequate notes prevented assessment of his inquiry. George collapsed 24 days later during sparring with evidence of rebleeding from a chronic subdural membrane. Had either the 31 October or 5 November imaging been performed, or had George been properly advised not to return to boxing pending investigation, his death likely would have been prevented.