AD - Non-inquest findings

Contributing factors

• Delayed diagnosis of STEMI by emergency department staff
• Delayed diagnosis of STEMI by cardiology staff
• Failure to carefully compare and study sequential pre-hospital and hospital ECGs
• Failure to immediately escalate after first hospital ECG showed diagnostic ST elevation
• Delayed CT aortogram investigation
• Delayed repeat ECG (requested at 8:50am but performed at 10:52am)
• Delayed troponin result
• Transfer to 'cold' zone of ED despite evolving STEMI
• Very busy emergency department
• Atypical clinical presentation with features suggestive of alternative diagnoses (aortic dissection, conduction disease)
• Patient appeared clinically stable and comfortable despite STEMI
• Approximately 10 hours delay to reperfusion (needle-to-skin at 5:15pm)
• Large completed anterior myocardial infarction by time of intervention
• Complications from late reperfusion including cardiogenic shock and pericardial effusion

Coroner's recommendations

1. Recommendations to the hospital's Safety & Quality Committee for a body of work relating to auditing ECG machines, interpretation of ECG reports and clear escalation processes for abnormal ECG findings
2. Audit and review of all ECG machines and algorithms with sensitive computerised diagnostic skills, with findings to inform assessment of which ECG machines perform the best reporting formats
3. Initiation of a new process in the emergency department requiring the most senior medical officer on duty to review every ECG and sign off a stamped template on the ECG with name, signature and written explanation of the importance of any critical abnormal findings
4. Discussion of whether similar ECG review and sign-off process can be initiated across the hospital
5. Reinforcement of the importance of clinicians carefully studying all available ECG reports including pre-hospital ECGs
6. The importance of timely review and escalation of abnormal ECG findings