Preventable Tragedies: Lessons from Adriana Smith's Story
Where Adriana Smith could have been saved—and how we build systems that intervene before it’s too late.
Adriana Smith did what patients are taught to do:
She recognized a serious symptom.
She sought emergency care.
She came back when it didn’t get better.
And still—she was sent home. Twice.
No imaging. No escalation. No diagnosis.
By the time anyone took her seriously, she was brain dead.
This post is not about blame. It’s about prevention.
And the uncomfortable truth is: Adriana’s death was not inevitable.
There were moments—clear, visible, preventable moments—when someone could have acted.
And someone didn’t.
🩺 Point of Intervention #1: The First Headache Should Have Triggered Alarm
A severe, new headache in early pregnancy is a red flag. It should prompt:
Blood pressure checks
Urinalysis for protein
Neurologic exam
At minimum, consideration of imaging
What might have helped:
✅ A clinical decision support tool that flagged “severe headache in pregnancy” as high-risk
✅ A digital triage system that prioritized neuro workup
✅ An OB or ER protocol that automatically escalated persistent neurologic complaints
Bottom line: If she’d had a CT scan at the first hospital, her brain clots might have been caught—and treated—before her collapse.