Inquest into the death of Brendan BURNS

24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of the brain

Brendan Burns, 24, died from acute hydrocephalus caused by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over one week. On 25 January 2009, Dr H. at Hay Hospital, concerned about possible space-occupying lesion, arranged urgent transfer to Griffith Base Hospital for CT scan. However, Drs Hall and Wark misdiagnosed alcohol withdrawal despite weak evidence (patient abstinent 2 weeks, minimal withdrawal screen), and discharged him without imaging. Brendan suffered catastrophic brain herniation overnight and died in Sydney the next day. The coroner found the failure to order CT scan despite clear red flags—referring doctor's explicit concerns, concerning history, and significant neurological deficits—was a serious and inexplicable clinical lapse. Early diagnosis and surgical drainage could potentially have altered outcome. Key lessons: recognise diagnostic anchoring bias, obtain complete patient history, appropriately weight referral information and clinical red flags, and ensure diagnostic uncertainty prompts investigation of serious pathology.