Coroner's Finding: TAYLOR Margaret Joyce

56y · Female·subarachnoid haemorrhage complicating berry aneurysm of the right middle cerebral artery

Margaret Joyce Taylor, aged 56, died from subarachnoid haemorrhage due to rupture of a berry aneurysm on the right middle cerebral artery. She presented to three medical practitioners over 6 days with progressive occipital and neck pain, attributed to cervical neuralgia or facet joint dysfunction. The coroner found her presentation was atypical of subarachnoid haemorrhage and could represent a 'warning leak'. Dr M. appropriately considered SAH as a differential diagnosis but excluded it clinically. The coroner made no criticism of the practitioners' failure to diagnose, noting that even tertiary institutions misdiagnose SAH in up to 30% of atypical presentations. However, the coroner criticised Dr W.'s inadequate documentation and examination. The coroner recommended that GPs entertaining SAH as a differential diagnosis should seek specialist advice rather than attempting to exclude it in primary care.