Medical shortfalls in Tas woman's death

A coroner has slammed a "cruel trifecta" of medical failures that could have prevented the death of a Hobart woman.

Anne Maree Woulleman-Jarvis, 62, died in July 2015, eight days after she fell and hit her head on bitumen.

A CT scan showed an intracranial haematoma, which a radiologist failed to identify, meaning Ms Woulleman-Jarvis was not referred to a neurosurgeon as she should have been.

When she attended the Royal Hobart Hospital's emergency department two days later complaining of worsening headaches, nausea and ineffective pain relief, the most junior medical intern on duty sent her home without a repeat scan.

Coroner Rod Chandler noted in his findings published on Wednesday that it was a particularly busy night when Ms Woulleman-Jarvis attended the hospital.

"In my opinion, Ms Woulleman-Jarvis was the victim of a cruel trifecta," he said.

"Ms Woulleman-Jarvis's death would, in all likelihood, have been prevented had any one of these factors not arisen."

A referral to a neurosurgeon, even at the time of her hospital presentation, would have led to life-saving treatment, Mr Chandler said.

Instead, Ms Woulleman-Jarvis died at home.

The coroner noted that the haematoma was 7mm and difficult to detect on the scan, but that the radiologist's failure to identify it constituted an error.

At the time of her fall, which occurred while collecting timber from a building site, Ms Woulleman-Jarvis already had an extensive medical history including heart surgery, asthma, depression, psoriasis and severe arthritis, and she usually used a stick or four-wheel walker for stability.

© AAP 2017

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