Finding into death of Mark James O'Brien

56y · Male·Complications of atraumatic bilateral femoral fractures (repaired) during a seizure in the setting of Down Syndrome

Mark O'Brien, a 56-year-old man with Down syndrome and dementia, sustained multiple seizure-related bilateral femoral fractures. A subtle posterior cortical fracture to his left femur, sustained during a seizure on 15 June 2019, was not identified on initial imaging on 17 June 2019, despite clinical concerns about pain and reluctance to mobilise. The fracture went undiagnosed for 9 days until a CT scan on 26 June 2019, during which time Mr O'Brien continued rehabilitation on an unstable leg. He suffered a third seizure on 19 July 2019 with further fracture displacement, was palliated, and died three days later. The initial misdiagnosis occurred partly because the fracture was rare and subtle, located at the imaging periphery, and the radiological referral lacked clinical context about the recent seizure and pain. Monash Health implemented educational measures and augmented staff orientation programs to reinforce complete clinical information in imaging requests.