Inquest into the Death of Davies, Adriana Elise

46y · Female·brain swelling and dural venous thrombosis in association with low grade glioma of the brain

Dr D., a 46-year-old medical practitioner, died from brain swelling and dural venous thrombosis associated with a low-grade glioma. She presented to Albany Hospital on 10 October 2005 with a severe, different headache characterized by pulsatile pain, photophobia, vomiting, and visual disturbances. Dr G. diagnosed migraine based on her history and symptoms, but failed to conduct comprehensive neurological examination or assess for papilloedema despite multiple red flags. He did not consider alternative diagnoses despite the patient explicitly stating this was unlike her usual migraines and her known brain tumour. The admission of a second doctor that evening recognized a different headache pattern. Dr G. repeated failure to examine neurologically on the ward the following morning, despite ordering CT imaging, represented missed opportunity for earlier escalation. The actual pathology—acute cerebral swelling with venous thrombosis—would have benefited from urgent neurosurgical input at first presentation. Key clinical lessons include: maintain diagnostic uncertainty with atypical presentations, always examine yourself even if others recently have, and aggressively investigate headache with focal neurology in patients with known CNS pathology.