Source : Perth Now news
A coroner has urged medical authorities to listen to the concerns of parents, after ruling that the death of a stroke patient diagnosed with a migraine could have been prevented.
Kate Sylvia, 32, a school librarian at Adelaide’s Pembroke College, had messaged her parents on December 2, 2021, stating: “sorry, migraine pain. Agony, dying on the bathroom floor”.
During a subsequent phone conversation, Kathryn Sylvia noticed that her daughter – who had a history of migraines – was “speaking like a drunk person”.
The inquest, conducted by South Australian Deputy Coroner Naomi Kereru, heard that Ms Sylvia’s parents were so concerned for her health that they immediately returned from Mildura, where a close relative was receiving end-of-life care.
Mrs Sylvia called SA Ambulance, which took her daughter to an Intermediate Care Centre at Sefton Park.
A doctor examined her and said he thought she was having a migraine episode.
When Mrs Sylvia arrived at the centre, she raised concerns with medical staff because her daughter’s headache “did not appear normal for her”.
“This was a pivotal point in Kate’s care,” the coroner said.
A doctor told Mrs Sylvia to “take her home, put her in a dark room, leave her there and let her sleep it off”.
Mrs Sylvia told the court that the morning after being discharged, her daughter continued to vomit, was sensitive to light, and was acting “like someone under anaesthetic”.
She took her daughter to the Queen Elizabeth Hospital, where a scan showed she had a right temporal haematoma.
But a radiology consultant missed the diagnosis of cerebral venous sinus thrombosis, a rare type of stroke involving a blood clot in the brain’s venous sinuses.
Ms Sylvia was transferred to the Royal Adelaide Hospital after a five-hour wait for an ambulance.
Subsequent surgical procedures were unsuccessful and she died on December 6, 2021.
“The overwhelming conclusion is that Kate’s death was preventable,” Ms Kereru found.
“The opportunities to prevent Kate’s death are clearly established.
“If those opportunities were taken, Kate would have been sent for a scan.”
The case highlighted “the danger of not affording adequate weight to the concerns of worried parents or caregivers in clinical situations”, the coroner found.
Greater attention may well have increased the chance of preventing Kate’s death, she said.
Ms Kereru recommended SA Health consider a program to allow family members in hospitals to escalate care when they consider their concerns are not being treated seriously.
A similar program was rolled out across NSW public hospitals after the 2024 death of toddler Joe Massa.
Mrs Sylvia told AAP that clinicians “need to listen to family”.
“A scan of the brain (is) quick and easy and only costs Medicare $200,” she said.
“I believe Sefton Park now has a scanning machine; I just hope doctors use it rather than risk misdiagnosis.”
