Coroner's Finding: Leary, Kane

17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision due to dissection of left internal carotid artery

Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left 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 terminal carotid vessel on over 6,500 images—missed despite being visible to experienced specialists. Early neurosurgical consultation would likely have identified the injury before irreversible brain damage occurred. Had the dissection been detected within 6-8 hours, endovascular clot retrieval could have offered salvage. Key failures: (1) radiologist interpretation error on original scans; (2) absence of neurosurgical team consultation despite head trauma concern and GCS drop. Enhanced trauma protocols, quality-controlled radiological services, and lower thresholds for specialist consultation in polytrauma with head injury are essential preventive measures.