Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite concerning features including severe headache (9/10), vomiting, pupil changes, and progressive drowsiness. A subdural haemorrhage (acute on chronic) was not diagnosed until transfer to a regional hospital, by which time he had deteriorated with aspiration pneumonia and brain herniation. Critical failures included: cognitive bias anchoring on alcohol withdrawal diagnosis; inadequate neurological examination and documentation; failure to obtain CT imaging despite red flags; continued diazepam administration despite signs of CNS depression (drowsiness, incontinence, fixed pupils); and delayed notification of medical staff about clinical deterioration. Although early CT scanning was limited by rural equipment availability, proper use of early warning tools (Q-ADDS) and escalation protocols could have prompted earlier medical review. The coroner concluded that while the outcome was likely unchanged, multiple opportunities existed to recognise and respond to deterioration.