Finding into death of Emilie Suzanne Le Coz

31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disconnected peritoneal catheter)

Emilie Le Coz, aged 31, died from raised intracranial pressure secondary to ventriculoperitoneal shunt disconnection. She presented to hospital in March 2010 with progressive headaches, cognitive changes and behaviour deterioration. Investigations including x-rays clearly showed the peritoneal catheter disconnected at C4-C5 level, but the neurology team misinterpreted findings alongside a reassuring shunt flow study and discharged her as migraine. The imaging was never reviewed by an experienced neurosurgeon. Her mother repeatedly raised concerns about shunt dysfunction that were not adequately heeded. Proper interpretation of x-rays by neurosurgery, or admission under neurosurgical rather than neurology team, would likely have prevented her death. Communication gaps between clinicians and carers, and junior staff reluctance to escalate concerns, were critical failings.