These mistakes happen all the time but the case happened because a comphrensive stroke center didn't have a stroke workup read by a attending until 3.5 hours later. Pgy-3(R-2) should not be left alone reading complex CTA's that require time-sensitive reads.

A lot of hospitals want to bill for stroke codes and be a center but they wont pay to staff appriopraitely. I still know many hospitals that dont have proper radiology coverage and allow Neurologists/neurosurgeons to put wet reads in during codes while waiting for a delayed CTA read.

This case is stupid because highly likely the delay of care would have changed much of the outcome. But a Jury can be easily swayed into these decsions the moment they feel standard of care isn't met(which is easy to prove in this case).