A CORONIAL inquest into the death of a man sent home from Griffith Base Hospital has found a CT scan could possibly have saved his life.
Deputy State Coroner Hugh Dillon found that Hay resident Brendan Burns died on January 27, 2009 at St Vincent's Hospital, Darlinghurst, of acute hydrocephalus due to an undiagnosed colloid cyst of the third ventricle of the brain.
Mr Burns, 24, visited Griffith Base Hospital on January 26 but was discharged in the middle of the night after doctors misdiagnosed him with alcohol withdrawal.
The next day, he died from a brain tumour at Sydney's St Vincent's Hospital.
The inquest found in the months prior to his death, Mr Burns had been suffering headaches.
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His partner, Liz Newman, had also noticed a change in his behaviour.
Mr Burns was initially seen be a doctor at Hay Hospital, who diagnosed sinusitis and recommended a CT scan, but Mr Burns was unwilling to make the trip to Griffith.
Then on January 25, 2009, Ms Newman discovered Mr Burns in immense pain lying on the couch at home and called an ambulance.
Neurological examinations performed by paramedics recorded he could not see, could not touch his nose with his finger and did not react to a hand passing in front of his eyes.
He was taken to Hay Hospital where the doctor feared he may have a brain tumour and referred Mr Burns to Griffith Base Hospital for an urgent CT scan.
When Mr Burns arrived at Griffith, Dr Hall's provisional assessment was that Brendan was suffering from alcohol withdrawal.
He discussed the case with Dr Wark, the emergency consultant.
When Dr Wark assessed Mr Burns, he appeared to be alert and was co-operative and the doctor formed the view that there was no need for an urgent CT scan.
Ms Newman came to collect Mr Burns to take him back to Hay and by that time, he was visibly unwell and had to be physically carried to the car and was unconscious for much of the journey home.
Mr Burns suffered a catastrophic brain herniation early on the morning of January 26, 2009.
Ms Newman recalled that it was after 6am in the morning that Brendan made a horrific noise and appeared to have a seizure.
An ambulance was called at 6:30am and was on scene by 6:40am, however, Mr Burns was non-responsive by this time.
He was flown to Sydney for emergency treatment but by that time irreparable damage had been done.
"I recommend to the Minister for Health, the Royal Australasian College of Surgeons and the Neurosurgical Society of Australasia that they consider implementing a scheme for organising regular short-form neurosurgical skills training for general surgeons operating in NSW regional centres," the coroner said.
The Murrumbidgee Local Health District (MLHD) said many changes have been implemented since Mr Burns' death..
"This was a very tragic incident and we again extend our sincere condolences and deepest sympathy to Brendan Burns' family and friends for their sad loss," said MLHD CEO Susan Weisser.
"The circumstances surrounding Brendan's death were thoroughly investigated by the former Greater Southern Area Health Service (GSAHS) and the recommendations that arose from an internal investigation have been implemented by Griffith Base Hospital and MLHD."