Coroner's Finding: McCARTHY Elly Sarahnia

13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema

Elly McCarthy, a 13-year-old girl, died from cerebral oedema and infarction secondary to subdural empyema. She developed fever, headache and neurological symptoms on 24 January 2004 and was initially seen at a GP and Noarlunga Health Service. When she returned with left leg weakness, she was appropriately transferred to Flinders Medical Centre where Dr T. performed an excellent clinical assessment, identified intracranial infection on CT imaging, and arranged urgent transfer to Women's and Children's Hospital for neurosurgery. The coroner found Elly's Glasgow Coma Score was 13-15 when she left Flinders, with a normal clinical trajectory. However, she suffered catastrophic brain herniation (coning) shortly after being loaded into the ambulance. Student ambulance officer DeLyster failed to recognise the significance of fixed dilated pupils at 4:30 am, took no corrective action, and the ambulance proceeded to Women's and Children's Hospital rather than returning to Flinders. The clinical lesson is that early recognition of neurosurgical emergencies and direct transfer to centres with paediatric neurosurgical capability is crucial; trainee ambulance staff require better supervision and understanding of critical vital sign changes.