Inquest into the death of Bradley Abala

12y · Male·astrocytoma (brainstem, posterior fossa tumour with hydrocephalus and brainstem herniation)

Bradley Abala, a 12-year-old Aboriginal boy, died from an aggressive brainstem astrocytoma on 23 April 2004. He presented with a three-month history of headaches, coordination difficulties, and lethargy. CT imaging on 20 April revealed a posterior fossa tumour with hydrocephalus. The clinical team appropriately consulted a neurosurgeon in Adelaide and arranged transfer for the following day, as neurosurgical facilities were unavailable locally. That evening, he developed vomiting and confusion suggesting 'coning' (brainstem herniation). Despite neurological examination showing apparent recovery, he deteriorated catastrophically at 5:55 am and could not be resuscitated. Independent expert opinion confirmed the decision to defer transfer was reasonable given his stable neurological status at diagnosis, unchanged ventricular size on serial imaging, and the low immediate risk of deterioration. However, the family was not notified when he deteriorated overnight, causing significant distress.