The death of a “kind, sweet” 32-year-old from a blood clot was preventable, with medical professionals missing two opportunities that could have saved her life, the deputy state coroner has found.
Kate Marie Sylvia died in December 2021 after a doctor diagnosed her with a migraine and sent her home to sleep it off.
On Wednesday morning, deputy state coroner Naomi Kereru handed down her report that stated the woman’s death could have been prevented if she had been referred to hospital for a scan.
Ms Kereru’s report found two missed opportunities for imaging would have ultimately saved the young woman’s life.
“The overwhelming conclusion is that Kate’s death was preventable,” the report stated.
“She was dealing with a condition that is diagnosable on readily-available imaging and has clear treatments that have very good success rates.
“If either of those two opportunities were taken, Kate would have been sent for a scan.
“On the balance of probabilities, (it) would have revealed abnormal intracranial pathology which would have then led to an ultimate diagnosis.”
Ms Kereru provided four recommendations to the health minister and the SA Health and SA Ambulance Service chief executives, including a directive for SA Health to consider a program allowing families to escalate hospital care when their concerns are not taken seriously.
Kate’s mother, Kathryn Jean Sylvia told the coronial inquest in December 2024 that a doctor at Hospital Avoidance and Supported Discharge Service in Sefton Park had informed her Kate was too young to have a stroke.
Ms Sylvia said the doctor had diagnosed her “kind, sweet” daughter with a migraine and told her to go home to “sleep it off”.
Kate and her parents were at the Queen Elizabeth Hospital for 12 hours, five of those waiting for a transfer to the Royal Adelaide Hospital to investigate a blood clot in her brain and multiple bleeds.
Her sister-in-law, Denise said outside court that (Kate) “was a beautiful soul, she was very special”.
In a statement SA Health offered its sincere condolences to the Sylvia family.
“Both the Department for Health and Wellbeing and SA Ambulance Service are reviewing the coroner’s findings handed down today and will consider the recommendations,” it said.