Coroner's Finding: Button, Shirley Gwendoline

69y · Female·subdural haematoma

A 69-year-old woman sustained a head injury from a witnessed fall, striking her head on a brick wall. She lost consciousness, experienced headache, vision problems and vomiting. CT imaging at the emergency department missed a subtle right tentorial subdural haematoma on initial scan, though the radiologist later acknowledged this was difficult to detect. A C3 vertebral fracture was also missed despite being mentioned in the radiological report. The patient's new-onset atrial fibrillation appears to have diverted clinical attention from the significant head trauma. The subdural haematoma expanded with midline shift and herniation, causing deterioration and death 48 hours after injury. While the initial haematoma detection was diagnostically challenging, the missed C3 fracture despite explicit mention in the report represents a concerning care gap with potential for serious harm.