Non-Inquest findings into the death of Ms G

76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain swelling and associated complications

A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm with signs of increased intracranial pressure. Critical delays occurred in escalating and transferring her to a neurosurgical centre. The regional hospital's junior doctor failed to escalate deterioration at 10pm, and the tertiary hospital's junior registrar underappreciated severity and did not escalate to a consultant. Systemic barriers included difficulty contacting the tertiary hospital switchboard and reluctance of junior staff to challenge tertiary advice. Earlier recognition of deterioration and direct consultant-to-consultant communication could have enabled timely transfer before irreversible neurological damage occurred.