Coroner's Finding: Wotton, Jeremy Dane

57y · Male·brainstem and cerebellar infarction due to vertebrobasilar artery thrombosis

A 57-year-old man with multiple cardiovascular risk factors presented to an ED with vertigo, blurred vision, and 'not feeling right' caused by an evolving posterior circulation stroke. A junior doctor discharged him after 3 hours, considering the vertigo peripheral rather than central. The patient deteriorated at home 2 hours later with classic stroke symptoms and underwent thrombectomy, but died from re-occlusion of the basilar artery. The coroner found the discharge premature: the doctor failed to adequately assess the patient holistically, did not exclude posterior circulation stroke, and should have admitted for observation rather than discharging. While earlier admission might not have prevented death (due to underlying atherosclerotic disease and vessel re-occlusion), the clinical approach was deficient, particularly underestimating the significance of atypical stroke symptoms, equivocal HINTS findings, unexplained visual disturbance, and multiple cardiovascular risk factors.