89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…
…gament disruption and spinal cord compression, converting the injury to a C5-C6 paraplegia/quadriplegia. An MRI scan would have detected the ligamentous injury and prevented mobilisation. The patient underwent delayed n…
71y · Male·disseminated fungal (Cryptococcus) infection of the lungs, brain and meninges
…ciousness, and neurological symptoms suggesting intracranial involvement, diagnostic workup was incomplete. MRI and lumbar puncture were not performed early enough to investigate CNS involvement. The patient was dischar…
55y · Male·Renal cell carcinoma (brain metastasis)
… reception to correctional custody on 16 September 2014. He was appropriately transferred to hospital where MRI imaging revealed a large right frontal brain tumour with metastatic renal cell carcinoma. He underwent unco…
72y · Male·cerebral malignancy (glioblastoma multiforme)
…maging identified three intracerebral lesions. He was promptly transferred to Royal Adelaide Hospital where MRI and PET scanning were conducted to locate a primary cancer. Neuroradiologist review confirmed glioblastoma …
63y · Male·disseminated carcinoma (pancreatic cancer with metastases to liver and lung)
…ad refused imaging investigations due to unfounded concerns about radiation, despite recommendations for CT scanning from November 2017 onwards. An MRI scan performed in June 2019 revealed advanced pancreatic cancer with…
33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…
…owever, the diagnosis of cerebral venous thrombosis (CVT) was not pursued despite radiologists recommending MRI. Poor communication between radiologists and neurosurgeons meant the on-call neurosurgeon was given an inco…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
… stroke on 7 September and arrange urgent transfer to the Stroke Unit at Royal Hobart Hospital. Instead, an MRI was delayed 4 days. When the MRI eventually revealed basilar artery thrombosis with extensive infarction on…
51y · Male·metastatic small round cell malignancy (Ewing's Sarcoma)
…tment of acute neurological presentations in custody settings should proceed as in the community, and early MRI imaging may be warranted when infection cannot be excluded in immunocompromised patients with unexplained s…
20y · Male·sudden unexplained death in epilepsy (SUDEP); right frontal lobe epidermal cyst …
…medical history of epilepsy and prior neurosurgery, he was discharged the same day without neuroimaging (CT/MRI scan), given only analgesia and paracetamol-codeine. He died of sudden unexplained death in epilepsy (SUDEP…
31y · Male·metastatic alveolar soft part sarcoma
…initiated pain complaints from 2010-2012 concerning left hip/back pain were unrelated to sarcoma; attempted MRI investigations were repeatedly cancelled but expert confirmed spinal pathology explained symptoms. After di…
64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall
Ian Gould, a 64-year-old man with a non-MRI compatible pacemaker, presented with vision loss in June 2019. Initial neurological and ophthalmological ev…
63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…
…initial CT imaging at 10:44am identified significant cervical spine injuries, but critical imaging results (MRI and CT angiogram) were delayed approximately 4.5 hours. The patient deteriorated acutely around 5:15pm duri…
55y · Male·Haemorrhagic brain stem infarction due to hypertensive heart disease
…y (one in the bathroom, one near his bed). Initial imaging showed no acute pathology, but subsequent CT and MRI scans revealed subarachnoid haemorrhage and extensive brain stem infarction. He was transferred to Brisbane…
54y · Male·Complications including hepatic encephalopathy, pneumonia and multi-organ failur…
…ment and care was reasonable and comparable to or better than community care. A minor delay in surveillance MRI scheduling was outside departmental control and unlikely to have changed the outcome. Rapid decompensation …
60y · Male·Respiratory obstruction (choking by food)
…e. His mumbling and slurred speech, which concerned his sister, was thoroughly investigated including brain MRI with no organic cause identified. The coroner found his medication was appropriately managed with clozapine…
33y · Male·Marburg variant of multiple sclerosis
… When acute neurological symptoms emerged on 3 December, he received comprehensive investigations including MRI, lumbar puncture, and broad-spectrum antibiotics. A neurologist appropriately recommended plasma exchange a…
70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…
…e symptoms and was appropriately treated with dual antiplatelet therapy and enoxaparin for VTE prophylaxis. MRI revealed haemorrhagic transformation; antiplatelet therapy was ceased but enoxaparin was continued on the e…
21y · Male·Complications of blunt head injury resulting from at least two separate acts of …
…atoma and occipital fracture visible on CT imaging were not diagnosed; the radiologist's recommendation for MRI was not pursued despite suspicion of non-accidental injury being raised; mandatory child protection reporti…
18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting…
…adache, nausea and dizziness. Dr H. reviewed him on 31 October with ongoing symptoms but did not order a CT scan, which the coroner found would have been prudent. George presented to Frankston ED on 5 November with persi…
53y · Male·metastatic pancreatic cancer
…old man incarcerated at Barwon Prison, presented with left flank pain and haematuria in November 2011. A CT scan in January 2012 identified concerning pancreatic duct distension suggesting possible pancreatic malignancy.…
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