Coronial
NTcommunity

Inquest into the death of Clive Henry Impu

Deceased

Clive Henry Impu

Demographics

25y, male

Date of death

2001-01-26

Finding date

2001-10-19

Cause of death

coronary thrombosis resulting from coronary atherosclerosis

AI-generated summary

A 25-year-old Aboriginal man with undiagnosed coronary artery disease collapsed and died one hour after a consultation at an Aboriginal health clinic. The coroner found the medical examination by Dr M. was inadequate and cursory. The deceased presented with chest pain, tingling in arms, and numbness—classic signs of ischaemic heart disease—but received only anti-inflammatory medication for presumed musculoskeletal pain. Dr M. did not physically examine the patient, take vital signs, or review the correct medical file. Prior opportunities to diagnose the condition in March 2000 were missed when ordered tests (exercise ECG, fasting cholesterol) were not performed and a specialist consultation was not pursued. The coroner identified multiple systemic failures including inadequate communication about ischaemic heart disease prevalence in young Aboriginal people and lack of direct access to exercise ECG testing in primary care.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practiceemergency medicineaboriginal healthcardiology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

anti-inflammatory medicationscelecoxibibuprofenindocidindoethacinaspirinantacidadrenalineatropine

Clinical conditions

ischaemic heart diseasecoronary atherosclerosiscoronary thrombosisacute myocardial infarctioncardiac arrestpulmonary oedemaheart failureasystolemyocardial fibrosis

Contributing factors

  • failure to diagnose ischaemic heart disease despite multiple presentations with chest pain
  • inadequate clinical examination by Dr M.
  • failure to perform ordered diagnostic tests (exercise ECG, fasting cholesterol test)
  • failure to follow up specialist clinic referral
  • wrong medical file retrieved during consultation
  • lack of awareness of higher prevalence of ischaemic heart disease in young Aboriginal people
  • systemic failure at Congress to follow up patient
  • minimal history taking and no physical examination during final consultation
  • presentation atypical for coronary disease (right-sided chest pain, shoulder/armpit pain)

Coroner's recommendations

  1. Steps be taken by Territory Health Services to allow general medical practitioners in Alice Springs to order exercise ECGs directly without requiring patients to see a specialist first
  2. All medical practitioners in Central Australia undergo specific orientation regarding the greater prevalence of chronic disease amongst Aboriginal people compared to the wider population, including the prevalence of ischaemic heart disease, as soon as possible after commencement of medical practice
Full text
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Source and disclaimer

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