Missed chances to save woman's life after fatal stroke misdiagnosed as migraine

Mother of school librarian misdiagnosed with migraine before fatal stroke urges clinicians to listen In short: A coroner has found the death of Adelaide woman Kate Sylvia was preventable. The 32-year-old was diagnosed with a migraine, days before dying from a brain bleed and clot. The coroner found she should have been correctly assessed and taken to hospital. An Adelaide woman incorrectly diagnosed with a migraine was twice failed by the health system in the lead-up to her death from a stroke, according to a deputy coroner who recommended that families be given more opportunity to raise red flags when their "concerns are not being taken seriously". Kate Marie Sylvia, a librarian for Pembroke Middle School, died in December 2021 from a cerebral venous sinus thrombosis days after she started experiencing vomiting, a stabbing head pain and slurred speech. The 32-year-old's death was the subject of a coronial inquest which today delivered its findings, which included the "overwhelming conclusion" that her death was preventable. Four days before Ms Sylvia died, an ambulance had taken her to an intermediate care centre at Sefton Park where a doctor gave her medication and told her to "sleep it off". Deputy coroner Naomi Kereru found the ambulance service should have correctly assessed her symptoms and taken her straight to hospital, and that the doctor at the care centre, Lyall Henderson, should also have referred to her hospital. "If either of those two opportunities set out above were taken, Kate would have been sent for a scan which, on the balance of probabilities, would ... then have led to an ultimate diagnosis,"she said. In findings handed down today, Ms Kereru wrote that Ms Sylvia's mother Kathryn Sylvia had called the ambulance, reporting that her daughter could not "talk properly" and "sounded like a drunk person". The deputy coroner said a paramedic who later physically assessed Ms Sylvia did "not record the speech disturbance [her mother] originally reported to the operations centre" and that, after completing his own assessment, recorded "no speech disturbance" in his clinical notes. "He agreed that he did not have knowledge of Kate's baseline as her mother would have," the deputy coroner said. After taking direction from the health navigator service, SA Ambulance took Ms Sylvia to an intermediate care centre at Sefton Park, which operates as one of SA Health's hospital avoidance clinics. The deputy coroner said she was struck by the "overly complicated way in which the communication took place between the SA Ambulance Service and the hospital avoidance and supported discharge service". "The process contributed to the loss of critical information about Kate's presentation … [and] the speech abnormalities reported by her mother," she said. "Had this information been passed on through a more direct line of communication, evidence was heard that Kate would have been diverted to a tertiary hospital." The deputy coroner recounted evidence from the paramedic about his handover to the Sefton Park centre, which did not have a CT scanner. "He said that he would be criticised if he handed over that Kate had trouble talking, but then she did not have trouble talking, so he did not mention her speech," Ms Kereru said. Mrs Sylvia previously told the inquest her daughter was given fluids, anti-nausea medication and aspirin, before being discharged by a doctor with a migraine diagnosis. "I said to him [the doctor], 'She doesn't normally get migraines'," she told the court. "He said, 'She told me she gets two a year', and I said, 'No, they're not medically diagnosed migraines'." Mrs Sylvia said when she questioned the doctor about why her daughter still sounded "groggy" and "slurry", he told her that Ms Sylvia was potentially still experiencing the "lasting effects" of green whistle pain relief medication Kate had received at the centre. "The more fundamental issue that arose was the doctor's lack of probing on the issue of Kate's speech when specifically raised by Mrs Sylvia,"Ms Kereru said. "It is simply good medicine to take the next step of investigation to rule out the most serious condition." 'Clinicians need to listen', grieving mum says Ms Sylvia died at the Royal Adelaide Hospital four days after her initial presentation at the Sefton Park clinic. In her findings, Ms Kereru said Ms Sylvia was "dealing with a condition that is diagnosable on readily-available imaging and has clear treatments that have very good success rates". The deputy coroner said that, after reviewing "competing expert evidence, the overwhelming conclusion is that Kate's death was preventable" and that two opportunities were missed. She said that SA Ambulance should have taken Ms Sylvia straight to hospital, instead of the care centre. "This would have involved the ambulance service correctly assessing the symptoms reported by Mrs Sylvia ... or alternatively Dr Henderson being advised of those concerning features during the intake process and declining to accept Kate," Ms Kereru said. She said that Ms Sylvia should also have been referred to hospital from the centre. "This would have involved Dr Henderson referring Kate to hospital after either conducting a more in-depth neurological examination than he genuinely did and detecting the severity of her condition, or alternatively probing in more detail as to whether Kate had actually been diagnosed with migraine previously, or alternatively placing sufficient weight on Mrs Sylvia's statements about Kate's condition," the coroner wrote. The deputy coroner made several recommendations to SA Health and the SA Ambulance Service, including that "paramedics are reminded of … the importance of not filtering information about patients". She also urged that SA Health routine training be updated, and clinicians be reminded that reports of migraine should be probed in detail and that "collateral information about a patient's presentation is valuable, particularly reports that a person being neurologically assessed is not themselves". "SA Health should give consideration to a program to allow family members in hospitals to escalate care where they consider concerns are not being taken seriously," Ms Kereru also recommended. Outside of the SA Coroners Court today, Mrs Sylvia became emotional midway through her interview with media. Her sister-in-law Denise Botten stepped in to support Mrs Sylvia. "[Kate was] just a beautiful soul," Ms Botten said. "I think the main takeaway is clinicians need to listen to family when you think things are not quite right, they need to be sure that they listen,"Mrs Sylvia added.