Epilepsy death: ED doctors investigated for failing to order brain CT scan


30 Sep 2019

Emergency doctors in Canberra who sent an epileptic man home with paracetamol and codeine to manage his severe headache have been referred to the Medical Board for investigation

The coroner overseeing an inquest into the sudden unexplained death in epilepsy  of a 20 year-old man in July 2016 said the ED doctors’ failure to order a CT brain scan was inappropriate medical treatment.

The inquest heard that the man had started to have seizures and headaches the previous year and had undergone surgery to remove a lesion on his frontal lobe 50x20x19 mm in size. He had a history of a dental cyst, but this had been found to be benign.

He was taking anticonvulsant medication following further seizures, and when he developed a bad headache six months later he presented to the Canberra Hospital emergency department.

After undergoing blood tests but no scan, he was discharged home and told to take Panadeine Forte if his headache persisted. He was found dead the next morning and a post mortem concluded this was due to epileptic seizure.

The inquest heard evidence from consultant neurologist Dr Ross Mellick that the man’s clinical history should have prompted further investigations such as a brain CT.

“A scan may have identified other information and pointed towards admission, which might have avoided a fatal outcome the following day,” the inquest was told.

“ Additionally, Dr Mellick stated that if Mr Pelle had been in hospital it is possible that an immediate response to the occurrence of a seizure may have enabled resuscitation which might have saved him.

The failure to perform a non-contrast CT scan was “outside the bounds of accepted medical practice, indeed it was wrong management,” the inquest was told.

The coroner concluded that the man did not receive appropriate treatment during his visit to The Canberra Hospital, and his treating doctors should be subject to a referral to the Medical Board, via the Australian Health Practitioners Regulatory Agency.

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