Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture and congenital arteriovenous malformation and multiple other medical comorbidities

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pain. Despite being unable to lie flat due to severe scoliosis and ankylosing spondylitis, he was positioned flat on the CT table using sedation and opioids. He reported hearing a crack and subsequently developed complete bilateral lower limb paralysis (ASIA Grade A spinal cord injury at T11/T12). The incident was preventable through: proper spinal precautions on admission; complete neurological assessment; involving family in care planning; and exploring alternative imaging options or positioning techniques. A sentinel event review identified multiple failures including trauma protocol non-compliance, anchoring bias, premature diagnostic closure, poor communication, and failure to escalate new neurological findings.