Coroner's Finding: Woulleman-Jarvis, Anne Maree 2017 TASCD 188

62y · Female·subacute subdural haematoma due to a closed head injury sustained in a fall from standing height

A 62-year-old woman on warfarin for a mechanical aortic valve sustained a head injury from a fall. A CT scan on day 5 post-injury identified a small extradural haematoma, but the radiologist (Dr J.) failed to report it, stating the scan was normal. The general practitioner accepted this normal report. Five days later, the patient presented to ED with worsening headaches unresponsive to opioids and nausea. Despite her anticoagulated status, recent head trauma, and concerning symptoms, the ED registrar (Dr P.) did not order a repeat CT scan, relying instead on the previous negative report. The patient was discharged home and died that night from the undiagnosed haematoma. The coroner found the death preventable through three failures: the radiologist's misreporting, the ED's failure to repeat imaging despite clinical red flags, and systemic ED understaffing that prevented proper senior review. The injury was treatable with 80-90% survival prospects if diagnosed on day 5, and remained treatable on day 11.