Finding into death of Kerri Louise Gunn

41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndrome (PRES)

Kerri Gunn, a 41-year-old woman five days post-caesarean delivery, presented to emergency with frontal headache, elevated blood pressure, proteinuria, abnormal liver function and lower limb oedema. She was admitted under general physician Dr S. after ED assessment by Dr McKenzie. A CT brain performed that evening was reported as normal. Despite clinical concern for cerebral venous thrombosis documented on the request form, further investigation with MRI was not pursued as Mrs Gunn improved symptomatically. She collapsed four days later with massive intracerebral haemorrhage secondary to posterior reversible encephalopathy syndrome (PRES). The coroner found that further radiology, particularly MRI, should probably have been ordered when the CT was discovered to have been performed without contrast. PRES was extremely rare and difficult to diagnose clinically. While earlier recognition might theoretically have allowed treatment with antihypertensive therapy, medical evidence suggests outcome may not have changed given the high risk of haemorrhage.