McKenzie, Jillian Peta

Contributing factors

• Failure to follow National Heart Foundation Guidelines for acute coronary syndrome management
• Misclassification of patient as low risk rather than intermediate risk despite presenting chest pain
• Overly confident diagnosis of muscular pain (99% certainty) without exclusion of cardiac cause
• Failure to admit for serial cardiac testing (ECG and troponin) as per protocol
• Absence of clear, firm advice to attend Cairns Base Hospital for definitive testing
• No documentation of cardiac risk discussion in hospital notes
• Unsupervised junior doctor without access to senior oversight
• Patient reluctance to attend larger hospital due to anticipated wait time (7 hours)

Coroner's recommendations

1. The appropriate authorities in Queensland Health should ensure that the measures taken at Babinda Hospital (as set out in Professor Brown's supplementary report regarding acute coronary syndrome management) are implemented at all level one hospitals in Queensland.
2. If a junior doctor is sent to relieve at a hospital such as Babinda, the most senior available doctor should be sent.
3. If a second-year doctor or any other junior doctor is to be sent to relieve at a hospital such as Babinda, only a doctor who has completed the Continuing Rural Skills Enhancement Course and completed the junior doctor curriculum framework by completion of competencies-based modules should be sent.
4. Clear lines of communication must be set up for all junior doctors relieving at hospitals such as Babinda to access senior practitioners at all times.