George Diamond died at the Alfred Hospital in Melbourne from bleeding near his brain on February 21, 2019, with an autopsy revealing an older subdural haemorrhage from a previous head injury.
An inquest investigating the links between the head knock he suffered in October 2018 and his death after collapsing at the Sting Gym four months later found several missed opportunities for doctors to detect the condition as they did not order brain scans despite his ongoing symptoms.
Mr Diamond visited two doctors, Pejman Hajbabaie and Yigal Reuben, with his father after being punched in the groin and head at the Cranbourne West gym on October 25.
Both doctors sent him away without ordering a CT scan or MRI.
Mr Diamond's symptoms persisted and his father, Vic Diamond, took him to Frankston Hospital on November 5, concerned that he was not getting better.
His father begged the attending emergency physician Dr Reuben for a CT scan or MRI.
Dr Reuben diagnosed Mr Diamond with concussion but said the scans were unnecessary and recommended against playing sport while the symptoms were ongoing.
Mr Diamond was medically suspended from the Sting Gym after the October concussion but returned to regular training in late December 2018 or early January 2019, before increasing his intensity after receiving a certificate of fitness from Dr Hajbabaie.
On 18 February 2019, Mr Diamond sparred at the gym before collapsing.Â
He died in hospital three days later.
Coroner John Cain on Monday delivered his findings that Dr Hajbabaie and Dr Reuben should have ordered Mr Diamond undergo a CT scan on multiple occasions.
"Had a CT scan been undertaken on 5 November 2018, it is more likely than not that it would have revealed that George had a subdural haematoma," he said.
He also found Dr Hajbabaie's note-keeping of his two appointments in October 2018 and January 2019 fell well below standard, which contributed to his decision to sign off Mr Diamond's return to boxing despite his lingering symptoms.
The coroner recommended there be more stringent requirements for individuals to be cleared before commencing amateur combat sports for the first time and before returning following injury.
He urged the peak bodies representing neurosurgical, GP, and sports and exercise doctors develop mandatory training in medical clearance for people beginning or returning from injury to combat sports.
Judge Cain also recommended the bodies develop guidelines on the appropriate threshold for undertaking a CT scan or MRI of a person's brain where injury has occurred in boxing or mixed martial arts.
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