A 35-year-old Aboriginal woman with schizoaffective disorder presenting with acute psychosis and chest pain was appropriately referred for psychiatric assessment and retrieval. CareFlight transport was timely and the receiving ED team initiated appropriate chest pain investigation including troponin, ECG, CTPA and D-dimer testing. However, she suffered a rare Type A aortic dissection with acute aortitis, an extremely uncommon diagnosis in young women without typical risk factors. The coroner found that despite appropriate sequential diagnostic reasoning, the dissection extended and caused cardiac arrest before diagnosis could be made. Even if diagnosed that evening, transfer to Adelaide for cardiothoracic surgery (unavailable in Darwin) would not have been achievable in time. The coroner determined the death was unavoidable despite best efforts by all treating teams.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
emergency medicinepsychiatrycardiologyretrieval medicine
pericardiocentesisthoracotomyechocardiographyCT pulmonary angiographypoint-of-care blood testingelectrocardiographyintravenous fluid administrationadvanced life support
Contributing factors
Type A aortic dissection - rare presentation in young woman without typical risk factors
acute aortitis with suppurative inflammation
pericardial effusion with clotted blood causing cardiac tamponade
absence of on-site cardiothoracic surgery service at Royal Darwin Hospital
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.