Coroner's Finding: Mr M

41y · Male·large volume thrombotic stroke within the distribution of the right posterior cerebral artery and posterior inferior cerebellar artery with basilar artery thrombus

A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange urgent transfer to the Stroke Unit at Royal Hobart Hospital. Instead, an MRI was delayed 4 days. When the MRI eventually revealed basilar artery thrombosis with extensive infarction on 10 September afternoon, the LGH radiology department failed to contact NWRH clinicians, and NWRH staff were unaware they could access results via PACS system. This 21-hour delay in receiving the MRI result, combined with the initial diagnostic error, meant transfer occurred too late. Had the patient been transferred on 7 September with prompt diagnosis, anticoagulation and neurovascular intervention offered real prospects of functional recovery.