Coroner says misdiagnosed migraine led to preventable death of Adelaide librarian

Deputy coroner Naomi Kereru ruled that the death of 32-year-old librarian Kate Marie Sylvia in December 2021 was preventable after a cascade of errors. An ambulance took her to Sefton Park's intermediate care centre, where Dr Lyall Henderson prescribed migraine medication and discharged her without imaging. The paramedic omitted the speech disturbance reported by Sylvia's mother, Kathryn, and the ambulance service did not transport her directly to a hospital.

The coroner highlighted the confusing hand-over process between SA Ambulance Service and the hospital-avoidance clinic, which lost critical information. Recommendations were made for SA Health and SA Ambulance to improve training, ensure family concerns are escalated, and avoid filtering patient details. Sylvia later died at Royal Adelaide Hospital from a cerebral venous sinus thrombosis.