The injury that led to the death of a Newnham teenager at the Launceston General Hospital was visible on just five of 6789 CT scan images seen by an emergency team, a coronial inquest heard.
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Dr Ashley Crosswell was the intensive care specialist in charge of an LGH review, known as a root cause analysis, of the medical treatment provided to seventeen-year-old Kane Leary.
Mr Leary was involved in a motorcycle crash at the corner of Tompsons Lane and Franmaree Rd, Newnham on May 27, 2021.
He suffered a number of critical injuries including a broken leg, broken scapula, abrasion to the forehead and a dissection of the left internal carotid artery which caused a stroke and resulted in his death.
The inquest heard that the dissection of the carotid artery had not been noticed on scans by medical staff at the LGH but had been seen by a specialist neuro-radiologist after Mr Leary's death.
Dr Crosswell said that the dissection was visible on just five of the 6789 scan images available to staff.
"How do you prevent something which is for want of a better word is bad luck?," he said.
He said that clinical assessment of the symptoms of the carotid dissection was clouded by the sedatives that Mr Leary was on and by other "distracting injuries" including the broken leg.
"It remains unknown whether the outcome would have been different if the carotid diagnosis was made earlier," Dr Crosswell said.
The inquest before coroner Robert Webster heard that the team leader of the medical team treating Mr Leary was required to consult with a specialist radiologist who was off site.
Under cross examination by counsel for Mr Leary's mother Melissa Bailey, Kim Baumeler, Dr Crosswell said the focus of the radiology had been on the leg. He said that normally about 4000 images would be taken. "Even knowing it [the carotid scan image] was there it is difficult to see the injury," he said.
It was akin to looking for a needle in a haystack. Mr Leary would have required neurosurgery in Hobart.
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Nick Clark
I am the Supreme and Magistrates Court reporter for the Examiner for the past 18 months. My journalism career has clicked over 30 years and encompasses four different spells at Tasmanian newspapers.
I am the Supreme and Magistrates Court reporter for the Examiner for the past 18 months. My journalism career has clicked over 30 years and encompasses four different spells at Tasmanian newspapers.
