Coroner's Finding: RUSSELL Michael John and GRAHAM Leslie Robert

Unknown·Michael Russell: intracranial haemorrhage complicating surgery for right cerebral artery occlusion complicating acute coronary syndrome due to bypass graft occlusion. Leslie Graham: left middle cerebral artery territory cerebral infarction

Two patients died following stroke interventions on 18 April 2017 at the Royal Adelaide Hospital. Michael Russell (60) died from intracranial haemorrhage following vessel perforation during thrombectomy for acute coronary syndrome; Leslie Graham (87) died from stroke progression after unsuccessful thrombectomy. The critical issue was that neither designated neurointerventional radiologist (Drs Taylor or Scroop) was available on the day, creating a crisis situation. Dr C., fortunately located nearby and listed on the CCINR register, was called in emergently. The coroner found that Dr S.'s arrangement to have Dr W. provide cover was inadequately communicated—Wilks understood he was only needed after hours, not for emergency stroke cases during business hours. The coroner criticised the autonomous, inadequately supervised INR service with only two permanent clinicians. Dr S. resisted nominating Dr C. due to personal antipathy despite his recognised competence. Systemic failures in recruitment and service planning meant no third INR was appointed despite clear need.