Finding into death of Craig Vincent Douthie

52y · Male·C2, C3, C4 spinal injury sustained from a fall secondary to seizures

A 52-year-old man with cerebral palsy, epilepsy, and intellectual disability living in disability accommodation fell in the bathroom after a seizure and sustained cervical spine fractures (C2-C3-C4). He was admitted to hospital with initially appropriate vital signs and neurological presentation. CT scanning was delayed by more than 15 hours due to difficulty understanding his neurological baseline, communication challenges, and technical issues with catheter insertion. The coroner found the diagnostic delay was not causal to his death and did not represent a missed opportunity for intervention. Earlier diagnosis would have been preferable and consistent with good practice, but his multiple comorbidities meant the outcome would not have changed. The disability accommodation staff provided appropriate immediate care. No systemic failures contributing to death were identified.