Coroner's Finding: Lumley, Barry Alyn

81y · Male·acute subdural haematoma

An 81-year-old man suffered a witnessed fall at a shopping centre with head strike to the right parietal region. He presented to the ED with a small haematoma and confusion. The ED team concluded he had a cardiac cause for syncope based on chest pain, referred him for cardiology, and did not perform a head CT scan despite clear evidence of head injury. The Canadian CT Head Rule, which mandates imaging for patients over 65 with head strike, was apparently considered but not executed. Two days later, he deteriorated with headache and was found unresponsive. CT imaging revealed a massive acute subdural haematoma. He died shortly after. Early CT imaging following the initial head injury would very likely have detected the haematoma and permitted intervention, potentially preventing death.