Finding into death of Michelle Louise Rosevear

41y · Female·Left middle cerebral artery territory ischaemic stroke

A 41-year-old registered nurse presented to the Emergency Department with altered consciousness on 28 May 2015. She was initially assessed as having a possible medication overdose rather than acute stroke, despite later learning she had reported weakness on her right side and suspected stroke that morning. A CT brain was not ordered initially; it was performed 8+ hours after presentation (8:21 pm), confirming a large left middle cerebral artery territory infarction. Emergency physician expert opinion concluded that medical management was sub-optimal because necessary investigations to confirm overdose or exclude stroke were not sufficiently thorough. However, even if stroke had been identified earlier, a neurologist's unchallenged opinion confirmed the patient was ineligible for thrombolysis due to uncertain time of symptom onset and extensive infarction on CT. The coroner found the failure to obtain timely CT was a regrettable deficiency but not a causal factor in death, since thrombolysis was contraindicated regardless. Peninsula Health conceded a CT should have been ordered earlier given diagnostic uncertainty.