Coroner's Finding: EDWARDS Natasha Anne

31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructive hydrocephalus, pressure coning and brainstem compression)

31-year-old woman presented with acute onset headache, dizziness, vomiting, facial numbness and speech difficulties. Initial CT brain showed equivocal left temporal hypodensity. Dr B. diagnosed acute migraine/benign positional vertigo and ordered lumbar puncture to exclude encephalitis, delaying neurological consultation. When lumbar puncture returned negative on Saturday afternoon, no reassessment occurred until next morning. The patient had actually suffered vertebral artery dissection causing cerebellar infarction. By Sunday she developed catastrophic cerebellar edema with obstructive hydrocephalus and herniation, causing brainstem compression and death. Expert evidence indicated 60-70% survival likelihood if condition recognized and treated with anticoagulation within 24 hours. Key failures: failure to follow up lumbar puncture results promptly on Saturday afternoon, failure to seek neurological consultation despite confusing presentation, failure to recognize vascular symptoms in young patient, and failure to pursue urgent weekend MRI despite radiologist recommendation.