Finding into death of Abigail Louise Cooke-Mitchell

42y · Female·Traumatic right subdural haematoma

A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment occurred when her partner called a home doctor service at 5.14pm reporting a major head injury with swollen face and severe headache, but the service failed to triage appropriately as an emergency requiring ambulance attendance. Instead, a doctor was assigned 3 hours later. The ambulance was only called at 9.36pm after the home doctor advised it was necessary. The patient was airlifted to hospital but had unsurvivable injuries. The systemic failures identified include inadequate telephone triage protocols by the home doctor service (missing symptoms of head injury requiring 000 activation), lack of scripted information about delays, and compounding delays from doctor workload and travel distance. While earlier ambulance attendance may not have altered outcome, the case demonstrates critical failings in emergency medical telephone triage that should trigger immediate specialist assessment.