An Adelaide woman who had slurred speech and "stabbing" head pain was diagnosed with a migraine and sent home to "sleep it off", days before dying of a brain bleed and clot, an inquest has been told.
South Australia's Coroners Court heard the 32-year-old patient, Kate Maria Sylvia, also had to wait several hours for an ambulance to transfer her between hospitals, before she died on December 6, 2021.
In an opening address on Tuesday, counsel assisting the coroner, Martin Kirby, told the court it was unknown whether doctors had prematurely diagnosed Ms Sylvia with a migraine "without excluding anything more serious".
"Ultimately, it's hoped that this inquest will identify how and why it was that those signs that showed that Kate was suffering from something more than just a migraine were not observed," he said.
Woman in 'agony' before discharge
Ms Sylvia's mother, Kathryn Sylvia, told the court her daughter sent her a text message on December 2, 2021, stating she was in "agony" and "dying on (the) bathroom floor".
She said when she later spoke to Ms Sylvia over the phone, her daughter was "speaking like a drunk person" and was "retching in the toilet and on the floor", prompting her to call an ambulance.
During a telephone call to the SA Ambulance Service, played in court, Mrs Sylvia told a dispatcher that her daughter had "huge stabbing pain" and felt "a bit frightened".
"She can't talk properly," Mrs Sylvia told the dispatcher.
"I wouldn't say she's completely alert."
Mrs Sylvia told the court that an ambulance arrived within minutes and took her daughter to the Intermediate Care Centre at Sefton Park, which operates as one of SA Health's "hospital avoidance" clinics.
She said her daughter was given fluids, anti-nausea medication and aspirin, before being discharged by a doctor with a migraine diagnosis.
"I said to him (the doctor): 'She doesn't normally get migraines'," Mrs Sylvia told the court.
"He said: 'She told me she gets two a year' and I said: 'No, they're not medically diagnosed migraines'."
Mrs Sylvia said when she questioned the doctor about why her daughter still sounded "groggy" and "slurry", he told her that Ms Sylvia was potentially still experiencing the "lasting effects" of the medication.
"He said: 'You just need to take her home, put her in a dark room, let her sleep it off," Mrs Sylvia said.
"He said: 'Statistically, people in their twenties and thirties don't have strokes'."
'Everything that's happened here is wrong'
Mrs Sylvia said the morning after being discharged from the medical centre, her daughter continued to vomit, was sensitive to light, had pins and needles in one hand, and was acting "like someone under anaesthetic".
She said she drove her daughter to the Queen Elizabeth Hospital, where she waited two hours before being assigned a bed in the emergency department.
"Kate's arm kept curling up," Mrs Sylvia told the court.
"She was touching the back of her head with her right hand and groaning."
A scan showed her daughter had a right temporal haematoma.
Nurses called an ambulance to transfer Ms Sylvia to the Royal Adelaide Hospital (RAH), but it took about five hours for one to arrive.
Mrs Sylvia said when her daughter arrived at the RAH, a doctor told her that Ms Sylvia's condition could have been caused by contraceptive pills, which she had recently started taking.
She said a social worker at the hospital told her to "get a lawyer".
"He said: 'This is wrong. Everything that's happened here is wrong'."
'This family deserves answers'
A post-mortem found Ms Sylvia died of brain bleeds and blood clots.
Outside court, lawyer Nick Xenophon, representing the Sylvia family, said Ms Sylvia's experience was "a trauma that no family should go through".
"We are very grateful that there's a coronial inquest because this family deserves answers, every South Australian deserves answers as to why this happened," he said.
"I think it's important that we get these answers so that this doesn't happen again to anyone else."
Mrs Sylvia said she felt like the "system failed her (Kate) on multiple times".
"If the system hadn't failed her, she would be with us today," she said.
"She should never have died."
The inquest continues.