Coronial

105 results for CT imaging of brain

TAShospital2025-03-17

Coroner's Finding: Phillips, Helen Lynette

77y · Female·intracranial haemorrhage (subdural, intraventricular and brainstem)

…ar-old woman fell from a ladder on 12 December 2022, suffering loss of consciousness and rib fractures. No brain CT scan was performed at Mersey Community Hospital despite the mechanism of injury and unconsciousness sug…

emergency medicinecardiologydiagnosticdelaythrombolytic agents
SAhospital2012-03-26

Coroner's Finding: SWEETMAN Amber Jayne

10y · Female·congenital hydrocephalus

…ressure (ICP) but the diagnosis was significantly delayed—approximately 90-100 minutes—because previous CT brain imaging stored at another hospital could not be electronically accessed for comparison. While her clinical…

emergency medicineneurosurgerydiagnosticcommunicationmidazolam
TAShospital2024-10-18

Coroner's Finding: Long, Leonard

73y · Male·subdural haematoma from fall

…ild head pain, and confusion, but the post-fall clinical pathway form was not properly completed and no CT brain was performed. A second fall occurred on 2 February without imaging. On 3 February, he deteriorated with a…

general medicineemergency medicinediagnosticsystemwarfarin
VIChospital2023-05-24

Finding into death of Mr V

73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…

…0. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequate for stroke evaluation) was performed instead of CT perfusion. He was discharged with prednisol…

emergency medicineneurologydiagnosticcommunicationprednisolone
TAShospital2015-09-07

Coroner's Finding: Weir, Mary

80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…

…icoagulation, causing seizures and deterioration. The coroner found the decision to anticoagulate without imaging was unsound practice and directly contributed to her death. Key lessons: always perform plain CT before a…

emergency medicinegeneral medicinediagnosticmedicationaspirin
VIChospital2021-04-08

Finding into death of Ian Lindsay Gould

64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall

…ilepticus on EEG, and ultimately sporadic Creutzfeldt-Jakob Disease (CJD) confirmed by lumbar puncture and brain biopsy. The coroner found that while BHS head injury guidelines did not reflect current standard practice …

neurologyophthalmologysystemrivaroxaban
VIChospital2014-01-30

Finding into death of Kerri Louise Gunn

41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndr…

…lower limb oedema. She was admitted under general physician Dr S. after ED assessment by Dr McKenzie. A CT brain performed that evening was reported as normal. Despite clinical concern for cerebral venous thrombosis doc…

emergency medicinegeneral medicinediagnosticdelayparacetamol
TAShospital2024-12-17

Coroner's Finding: Brown, Paul Louis

64y · Male·Subdural haematoma with mass effect following thrombolysis for acute myocardial …

…complex medical history including diabetes, mental illness, chronic alcohol misuse, and previous traumatic brain injury was admitted with diabetic ketoacidosis and acute kidney injury. He developed acute myocardial infa…

intensive carecardiologytenecteplase
QLDhospital2009-11-11

Baker, Philip

55y · Male·Haemorrhagic brain stem infarction due to hypertensive heart disease

… pain. He experienced two falls during his hospital stay (one in the bathroom, one near his bed). Initial imaging showed no acute pathology, but subsequent CT and MRI scans revealed subarachnoid haemorrhage and extensiv…

emergency medicinegeneral medicinemorphine
TAShospital2021-05-24

Coroner's Finding: Lumley, Barry Alyn

81y · Male·acute subdural haematoma

…t 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 det…

emergency medicinecardiologydiagnosticproceduralparacetamol
TAShospital2019-07-25

Coroner's Finding: Horcicka, Josef Vratislav

89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…

…with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematoma. Conservative ma…

orthopaedic surgeryemergency medicinediagnosticproceduralmorphine
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

…on, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass was suspected but …

orthopaedic surgerygeneral medicinesystemwarfarin
VIChospital2020-10-21

Finding into death of MRS M

91y · Female·Complications of pelvic fractures sustained in a fall

…rtly after antibiotic administration and died. Post-mortem CT revealed pelvic fractures missed on initial imaging. Key clinical lessons: the initial hip x-ray failed to detect pelvic fractures that contributed to her de…

emergency medicinegeriatric medicinediagnosticdoxycycline
VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

…bout the head injury. He was taken directly to the cardiac catheterisation lab without ED assessment or CT brain imaging. A skull fracture and intracranial haemorrhage subsequently developed, likely exacerbated by antic…

cardiologyemergency medicinediagnosticcommunicationheparin
SAhospital2020-06-17

Coroner's Finding: TIERNAN John Joseph

78y · Male·large left basal ganglia intracerebral haemorrhage with mass effect

… Inpatient Treatment Order (ITO) for acute hyperactive delirium. He had stage 4 lung cancer with extensive brain metastases discovered on MRI. His delirium was appropriately attributed to cancer rather than the initial …

psychiatryneurology
NSWhospital2014-05-09

Inquest into the death of Brendan BURNS

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

… 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 fo…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
TAShospital2017-04-19

Coroner's Finding: Sheedy, Barbara

77y · Female·Large acute subdural haemorrhage leading to uncal herniation subsequent to an ac…

…urs later, which were attributed to pre-existing pulmonary disease. A dilated pupil at 4:25am prompted CT imaging revealing large right-sided subdural haemorrhage with brain stem compression. Critical lessons: elderly p…

emergency medicinegeneral medicinediagnosticdelaytemazepam
VIChospital2025-10-28

Finding into death of Jean Elizabeth Crocker

90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …

…care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT brain imaging. Cardiology consultation for suspected myocardial infarction led to prescription of enoxaparin (a …

emergency medicinegeneral medicinemedicationdiagnosticwarfarin
VIChospital2025-04-30

Finding into death of Margaret Ann Day

66y · Female·Ischaemic brainstem stroke

…gia, presented to the Emergency Department on 26 November 2024 with acute focal neurological symptoms. CT imaging revealed bilateral occipital posterior circulation infarcts with basilar artery occlusion, placing her ou…

neurologyemergency medicinelevetiracetam
TAShospital2017-11-01

Coroner's Finding: French, Steven John

57y · Male·large volume ischaemic infarct (stroke)

…yocardial infarction (2009), presented with headache, visual disturbance and gait difficulty in May 2013. Imaging at Launceston General Hospital on 30 May demonstrated vertebral artery dissection, but this was not recog…

neurologyradiologydiagnosticcommunicationenoxaparin

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