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Coroner's Finding: Urgent, unexpected or sinister findings reported following medical imaging

The South Australian coroner has made a number of recommendations as part of his findings, delivered in June 2013, into the death of a 69-year-old woman who died as a result of left pontine haemorrhage associated with hypertensive vascular disease. The patient had a medical history which included tuberculosis, Bell’s palsy, diabetes mellitus, hypertension, hypercholesterolaemia and rheumatoid arthritis.

She attended her GP for a routine visit regarding her rheumatoid arthritis. The patient complained of slurred speech and was referred for a CT scan of her head. Nine days after her appointment with the GP, she had the CT. The scan showed a mass on the left side of the pons. The GP was notified by phone. He then requested that the patient be asked to attend his surgery for referral for neurological opinion.

Efforts were then made by the GP’s receptionist to make contact with the patient by telephone. The efforts were unsuccessful and the patient was later found deceased.

The coroner recommended that when urgent, unexpected or sinister findings are reported following medical imaging, the GP should ensure that if the patient concerned is not notified within 48 hours of the fi nding (or less if clinically indicated), the GP must make contact with the SA Ambulance Service or SA Police to ensure that a welfare check is conducted and that the patient is advised to contact his or her GP.

More information is included in the Coroner’s finding at www.courts.sa.gov.au.

The above article was published in the December 2013 issue of medicSA, teh AMA(SA) magazine.