A deputy coroner has found the death of Adelaide woman Kate Marie Sylvia was preventable after she was misdiagnosed with a migraine before dying from a cerebral venous sinus thrombosis in December 2021. The 32-year-old librarian for Pembroke Middle School had started experiencing vomiting, stabbing head pain and slurred speech days before her death at the Royal Adelaide Hospital. The machinery of care had the facts in front of it. It still failed her.
Who Had the Power
Deputy coroner Naomi Kereru found SA Ambulance should have correctly assessed Ms Sylvia's symptoms and taken her straight to hospital, and that the doctor at the intermediate care centre at Sefton Park, Lyall Henderson, should also have referred her to hospital. Ms Kereru said that if either of those opportunities had been taken, Kate would have been sent for a scan which, on the balance of probabilities, would have led to an ultimate diagnosis. That is the hierarchy at work: people in uniform, people with titles, people with the authority to decide whether a patient gets seen, scanned, or sent away.
Ms Sylvia's mother, Kathryn Sylvia, had called the ambulance and reported that her daughter could not "talk properly" and "sounded like a drunk person." The deputy coroner said a paramedic did not record the speech disturbance originally reported to the operations centre and later wrote "no speech disturbance" in his clinical notes. She said the communication between SA Ambulance Service and the hospital avoidance and supported discharge service was overly complicated and contributed to the loss of critical information about Kate's presentation. The system didn’t just miss a clue. It filtered it, buried it, and passed the damage down the line.
Who Paid the Price
Mrs Sylvia told the inquest she had questioned the doctor after her daughter was given fluids, anti-nausea medication and aspirin and discharged with a migraine diagnosis. She said she told him, "She doesn't normally get migraines," and later asked why her daughter still sounded "groggy" and "slurry." Ms Kereru said the doctor's lack of probing on the issue of Kate's speech was the more fundamental issue. She said, "It is simply good medicine to take the next step of investigation to rule out the most serious condition."
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. She said the overwhelming conclusion was that Kate's death was preventable and that two opportunities were missed. The language is clinical. The result is brutal. A young woman with symptoms that should have triggered urgent attention was instead sent back out into the world with a migraine label and no answer.
Outside the SA Coroners Court, Kathryn Sylvia became emotional during her interview with media. Her sister-in-law Denise Botten said, "[Kate was] just a beautiful soul," and Mrs Sylvia 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." That plea comes from the bottom, where the consequences land first. Families notice what institutions miss. They always do.
What They’re Calling Reform
Ms Kereru made several recommendations to SA Health and the SA Ambulance Service, including that paramedics be reminded of the importance of not filtering information about patients. She also urged that SA Health routine training be updated, and that 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. She also recommended that SA Health consider a program to allow family members in hospitals to escalate care where they consider concerns are not being taken seriously.
Those recommendations sit inside the same apparatus that failed Kate Sylvia in the first place. They may change a form, a reminder, a training session. They do not change the fact that the people closest to the patient had to fight to be heard, and still lost.
Dentists are making a similar case about another basic need pushed out of reach by the system. They have warned that one-third of Australian adults are experiencing tooth decay, with many unable to afford dentistry. More than 2 million Australians have skipped dental care because it was unaffordable, according to an Australian Dental Association survey, and more than 40 dentists gathered at Parliament House in Canberra to urge politicians to make progress on a national oral health plan.
The federal government has not yet finalised its National Oral Health Plan 2025 to 2034, despite consultations with dentists in 2024. ADA vice president Angie Nilsson said, "We're living in one of the richest countries in the world and we still have one-third of adults with untreated tooth decay." She said the problem becomes more expensive, more painful and more time-consuming when people do not go to a dentist early. Dr Nilsson also said 60 per cent of 18 to 25-year-olds are making decisions based on social media, which can lead to bleaching that can be unhealthy and damage teeth.
Emily Novo, a Sydney student, said she felt a slight pain above one of her wisdom teeth while brushing before bed, then woke up the next day unable to open her mouth. She said, "I couldn't even open it enough to brush my teeth, let alone eat a piece of toast," and later, "I was mortified, [I felt] just absolute pure panic." She went to her general practitioner, who could not get access to her mouth and sent her to a hospital emergency department. Ms Novo said, "From a cost point of view, it was really, really daunting," and said she was sent home with "some hardcore antibiotics." The antibiotics eventually worked, but she was unable to open her mouth properly for a week and said, "I was just eating soup all week, I couldn't eat properly, I couldn't talk properly."
ADA president Chris Sanzaro said, "Every day in our practices we see the cost of leaving dental care out of the health system," and added, "A National Oral Health Plan is not a luxury; it is essential to giving Australians the access to care they deserve." The politicians can gather, consult, and delay. People still have to live with the gap.