Finding into death of Reginald Desmond Benham

85y · Male·Intracranial haemorrhage in the setting of a fall in a man with multiple comorbidities (palliated)

An 85-year-old man with multiple comorbidities suffered a fall at home and was transported to hospital with stroke symptoms. A CT brain scan revealed subtle subarachnoid haemorrhage (traumatic), but the VST consultant neurologist missed this finding and recommended thrombolysis. ED clinicians appropriately relied on this expert advice and commenced Alteplase at 10:45pm. The radiologist's report identifying haemorrhage became available at 10:42pm but was not communicated to treating clinicians until 11:23pm—a 40-minute delay. By then, approximately half the thrombolytic infusion had been administered. The thrombolysis caused massive intracranial haemorrhage and death. While preventability could not be established with certainty, critical opportunities to avoid inappropriate treatment were lost due to: (1) the neurologist's missed subtle CT finding, and (2) the radiologist's failure to telephone findings to the referring doctor in accordance with policy and standards. The coroner emphasised that checks and balances like direct communication of urgent findings are essential to prevent such errors.