Coronial

106 results for CT brain imaging

TAShospital2024-03-27

Coroner's Finding: Leary, Kane

17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…

…t internal carotid artery dissection on initial CT scans (27 May 2021). Although appropriate angiographic imaging was ordered by the emergency physician, the radiologist failed to identify a subtle occlusion at the term…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
SAhospital2008-08-15

Coroner's Finding: EDWARDS Natasha Anne

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

…sented with acute onset headache, dizziness, vomiting, facial numbness and speech difficulties. Initial CT brain showed equivocal left temporal hypodensity. Dr B. diagnosed acute migraine/benign positional vertigo and o…

neurologygeneral medicinediagnosticdelaymetoclopramide
WAhome2007-09-14

Inquest into the Death of Jones Coronial

9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)

…was attempted but Dwayne died from cerebral coning. The coroner found the critical failure was delayed CT imaging. Early neurological imaging on 11 April would likely have changed the outcome. The case highlights the ch…

general practiceemergency medicinediagnosticdelayparacetamol
TAShome2016-07-14

Coroner's Finding: Bedford, Sidney

83y · Male·Acute subdural haemorrhage following a fall

…anticoagulation therapy. He was transported to Launceston General Hospital where an initial CT scan of the brain was misread as normal by radiologist Dr M., who failed to identify a small (3-4 mm) acute subdural haemato…

emergency medicineradiologydiagnosticwarfarin
WAhospital2013

Inquest into the Death of Davies, Adriana Elise

46y · Female·brain swelling and dural venous thrombosis in association with low grade glioma …

Dr D., a 46-year-old medical practitioner, died from brain swelling and dural venous thrombosis associated with a low-grade glioma. She presented to Albany Hospital …

general practiceneurosurgerydiagnosticcommunicationprochlorperazine
VIChospital2015-07-29

Finding into death of Beatrix Dammers

56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy

… signs is atypical for stroke; when patients deteriorate on anticoagulation, therapy should be ceased and imaging repeated immediately, not escalated; and patients with significant neurological events should be transfer…

emergency medicineneurologydiagnosticmedicationenoxaparin
VIChospital2023-08-01

Finding into death of Michele Valentino

81y · Male·Head injury sustained in a fall

…mmunication protocols for critical radiological findings, recognizing that isolated IVH requires specific imaging expertise, and implementing systems that detect human error before patient harm occurs.

emergency medicineradiologydiagnosticcommunicationaspirin
NThospital2000-10-31

Inquest into the death of Marcio Jose Lay Nheu

26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…

…, he was prematurely discharged after 40-50 minutes of assessment into police custody without CT or X-ray imaging. He was returned to the police watchhouse where he remained unresponsive. The following morning he was fo…

emergency medicineneurosurgerydiagnosticcommunicationtemazapam
QLD2026-03-31

Inquest into the death of Kyle James Gallagher

22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…

…reported to the on-call ENT junior doctor. The ENT Consultant failed to appreciate the seriousness of the imaging findings and did not conduct an appropriate clinical review. The junior ENT doctor did not escalate conce…

ENT surgeryradiologydiagnosticcommunicationdiazepam
SAhospital2023-04-28

Coroner's Finding: Adams, Geoffrey Gordon

72y · Male·cerebral malignancy (glioblastoma multiforme)

…r 2020 during a routine medical appointment in prison. Prison staff appropriately called an ambulance; CT imaging identified three intracerebral lesions. He was promptly transferred to Royal Adelaide Hospital where MRI …

neurosurgeryradiologywarfarin
VIChospital2022-08-29

Finding into death of Helen Welsh

63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities

…nd hypotension. A MET call was initiated and sepsis was suspected. However, clinical staff prioritised CT imaging over immediate antibiotic administration while awaiting blood culture results. She suffered cardiac arres…

cardiothoracic surgeryemergency medicinedelaydiagnosticcarbimazole
NSWhospital2025-12-08

Inquest into the death of Katrina McGrady

43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm

…eadaches (5-8/10) occurring 30 August–4 September to the treating neurosurgeon; delay in obtaining repeat imaging (CT/MRI) despite escalating headache severity; and inadequate informed consent discussion regarding treat…

neurosurgeryradiologycommunicationdiagnosticaspirin
NSWhospital2016-12-20

Inquest into the death George TRIANTAFILOPOULOS

75y · Male·acute right subdural haemorrhage sustained in a fall

…examinations, found GCS 15, and discharged him home with observation instructions. Neither GP ordered a CT brain scan despite the high-risk combination of age, anticoagulation, and head trauma. By 3pm on 15 August, Geor…

general practiceemergency medicinediagnosticdelaywarfarin
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 …

…irst hospital admission on 22-24 November 2013: a subdural haematoma and occipital fracture visible on CT imaging were not diagnosed; the radiologist's recommendation for MRI was not pursued despite suspicion of non-acc…

paediatricsemergency medicinediagnosticcommunication
NSWhome2024-11-04

Inquest into the death of MR

4y · Female·hypoxic brain injuries

A 4-month-old girl died from hypoxic brain injury following an unexplained, unnatural restriction of oxygen on 13 May 2017. She was found unresponsiv…

paediatricspathologydiagnosticdelay
TAShospital2017-05-17

Coroner's Finding: Woulleman-Jarvis, Anne Maree 2017 TASCD 188

62y · Female·subacute subdural haematoma due to a closed head injury sustained in a fall from…

… the death preventable through three failures: the radiologist's misreporting, the ED's failure to repeat imaging despite clinical red flags, and systemic ED understaffing that prevented proper senior review. The injury…

general practiceemergency medicinediagnosticcommunicationwarfarin
TAShospital2019-10-17

Coroner's Finding: Davies, Eva Fay

87y · Female·left frontal temporal subdural haematoma following closed head injury sustained …

…A CT scan confirmed acute subdural haematoma. The neurosurgical registrar advised observation with repeat imaging in 24 hours rather than urgent transfer. The coroner found this advice incorrect: anticoagulated patients…

neurosurgeryemergency medicinecommunicationdiagnostic
QLDhospital2016-09-15

Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

…sed until transfer to a regional hospital, by which time he had deteriorated with aspiration pneumonia and brain herniation. Critical failures included: cognitive bias anchoring on alcohol withdrawal diagnosis; inadequa…

emergency medicineneurologydiagnosticcommunicationdiazepam
TAShospital2014-03-14

Coroner's Finding: Little, Neita Jean

79y · Female·aspiration pneumonia caused by aspiration of emesis secondary to small bowel obs…

… warrants urgent investigation; (2) oxygen desaturation (3am) was a red flag requiring medical review and imaging which was not obtained; (3) Dr J.'s assessment at 9.45am, concluding discharge fitness despite seven vomi…

gynaecologyanaesthesiadiagnosticcommunicationrivaroxaban
NSW2016-09-14

Inquest into the death of Rodney James BATES

55y · Male·Traumatic brain injury caused by blunt force to the head sustained in a fall

Rodney Bates, a 55-year-old in custody at Cessnock Correctional Centre, died from traumatic brain injury sustained in a fall on 2 April 2015. He had experienced recurrent unexplained loss of consciousness…

neurosurgeryneurologymethadone

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