Coronial
TAShospital2019-07-25

Coroner's Finding: Horcicka, Josef Vratislav

89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…

…gament disruption and spinal cord compression, converting the injury to a C5-C6 paraplegia/quadriplegia. An MRI scan would have detected the ligamentous injury and prevented mobilisation. The patient underwent delayed n…

orthopaedic surgeryemergency medicinediagnosticproceduralmorphine
TAShospital2018-01-23

Coroner's Finding: Mr M

41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…

… stroke on 7 September and arrange urgent transfer to the Stroke Unit at Royal Hobart Hospital. Instead, an MRI was delayed 4 days. When the MRI eventually revealed basilar artery thrombosis with extensive infarction on…

emergency medicineneurologydiagnosticcommunication
QLDhospital2016-01-19

McCart, Thomas Gerard

55y · Male·Renal cell carcinoma (brain metastasis)

… reception to correctional custody on 16 September 2014. He was appropriately transferred to hospital where MRI imaging revealed a large right frontal brain tumour with metastatic renal cell carcinoma. He underwent unco…

neurosurgeryneurology
TAShospital2020-04-07

Coroner's Finding: Pettersson, Jan Axel

71y · Male·disseminated fungal (Cryptococcus) infection of the lungs, brain and meninges

…ciousness, and neurological symptoms suggesting intracranial involvement, diagnostic workup was incomplete. MRI and lumbar puncture were not performed early enough to investigate CNS involvement. The patient was dischar…

general medicinerespiratory medicinediagnosticdelay
VIChospital2014-01-30

Finding into death of Kerri Louise Gunn

41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndr…

… clinical concern for cerebral venous thrombosis documented on the request form, further investigation with MRI was not pursued as Mrs Gunn improved symptomatically. She collapsed four days later with massive intracereb…

emergency medicinegeneral medicinediagnosticdelayparacetamol
SAhospital2020-06-17

Coroner's Finding: TIERNAN John Joseph

78y · Male·large left basal ganglia intracerebral haemorrhage with mass effect

…O) for acute hyperactive delirium. He had stage 4 lung cancer with extensive brain metastases discovered on MRI. His delirium was appropriately attributed to cancer rather than the initial fall. A massive spike in blood…

psychiatryneurology
SAhospital2025-07-03

Coroner's Finding: Provis, Adam James

50y · Male·in-hospital cardiac arrest on a background of seizures and atheroembolic cerebro…

…rovascular disease. He presented with acute behavioural disturbance, confusion and seizures in August 2021. MRI revealed subacute lacunar infarcts of unclear source. Despite comprehensive investigations and neuropsychia…

psychiatryneurologythiamine
SAhospital2008-08-15

Coroner's Finding: EDWARDS Natasha Anne

31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…

…presentation, failure to recognize vascular symptoms in young patient, and failure to pursue urgent weekend MRI despite radiologist recommendation.

neurologygeneral medicinediagnosticdelaymetoclopramide
QLDhome2015-01-29

Daw, Lilly Ella - Non-inquest findings

1y · Female·cystic encephalomalacia

…umented 20% risk of neurological injury secondary to twin-twin transfusion syndrome, yet the planned foetal MRI to assess this was never performed. After premature discharge from neonatal care at <36 weeks without docum…

obstetricspaediatricscommunicationdelay
SAhospital2003-12-19

Coroner's Finding: HAWKE Anne Elizabeth

33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…

…owever, the diagnosis of cerebral venous thrombosis (CVT) was not pursued despite radiologists recommending MRI. Poor communication between radiologists and neurosurgeons meant the on-call neurosurgeon was given an inco…

neurosurgeryradiologydiagnosticcommunicationoral contraceptive pill
QLDhospital2009-11-11

Baker, Philip

55y · Male·Haemorrhagic brain stem infarction due to hypertensive heart disease

…y (one in the bathroom, one near his bed). Initial imaging showed no acute pathology, but subsequent CT and MRI scans revealed subarachnoid haemorrhage and extensive brain stem infarction. He was transferred to Brisbane…

emergency medicinegeneral medicinemorphine
VIChospital2017-06-29

Finding into death of Polina Portnyagina

78y · Female·Complications of a left tentorial meningioma

A 78-year-old woman with a meningioma detected incidentally on MRI in 2009 presented to hospital in 2015 with gait disturbance and falls. The tumour had grown significantly, …

neurosurgeryradiologydiagnosticsystemdexamethasone
NSWhospital2023-06-23

Inquest into the death of Baylen Pendergast

21y · Male·Complications of blunt head injury resulting from at least two separate acts of …

…atoma and occipital fracture visible on CT imaging were not diagnosed; the radiologist's recommendation for MRI was not pursued despite suspicion of non-accidental injury being raised; mandatory child protection reporti…

paediatricsemergency medicinediagnosticcommunication
QLDhospital2010-10-29

Spence, Samantha Rose

12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…

…severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric neurologist assessed her as cleared for surgery. Post-operatively, she developed…

orthopaedic surgeryneurologydiagnosticcommunicationmorphine
SA2022-03-30

Coroner's Finding: Papadopoulos, George

63y · Male·disseminated carcinoma (pancreatic cancer with metastases to liver and lung)

… unfounded concerns about radiation, despite recommendations for CT scanning from November 2017 onwards. An MRI scan performed in June 2019 revealed advanced pancreatic cancer with liver and lung metastases. The coroner…

general practicecorrectional health
SAhospital2023-04-28

Coroner's Finding: Adams, Geoffrey Gordon

72y · Male·cerebral malignancy (glioblastoma multiforme)

…maging identified three intracerebral lesions. He was promptly transferred to Royal Adelaide Hospital where MRI and PET scanning were conducted to locate a primary cancer. Neuroradiologist review confirmed glioblastoma …

neurosurgeryradiologywarfarin
VICmental health2023-05-22

Finding into death of Peter Henry Scerri

60y · Male·Respiratory obstruction (choking by food)

…e. His mumbling and slurred speech, which concerned his sister, was thoroughly investigated including brain MRI with no organic cause identified. The coroner found his medication was appropriately managed with clozapine…

psychiatryemergency medicineclozapine
VIChospital2020-02-28

Finding into death of Keith Walter Sharp

63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…

…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 duri…

emergency medicineradiologydelaydiagnosticaspirin
SAhospital2025-11-14

Coroner's Finding: Menzies, Jason Douglas

33y · Male·Marburg variant of multiple sclerosis

… When acute neurological symptoms emerged on 3 December, he received comprehensive investigations including MRI, lumbar puncture, and broad-spectrum antibiotics. A neurologist appropriately recommended plasma exchange a…

emergency medicinegeneral medicineamitriptyline
VIChospital2021-04-08

Finding into death of Ian Lindsay Gould

64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall

Ian Gould, a 64-year-old man with a non-MRI compatible pacemaker, presented with vision loss in June 2019. Initial neurological and ophthalmological ev…

neurologyophthalmologysystemrivaroxaban
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