Coroner's Finding: MARKANTONAKIS Stefanos
Deceased
Stefanos Markantonakis
Demographics
63y, male
Date of death
2004-03-06
Finding date
2007-09-18
Cause of death
uncontrolled haemorrhage from ruptured aortic aneurysm
AI-generated summary
A 63-year-old man presented with sudden back pain on 6 March 2004. Ambulance officers attended twice; on the first visit they did not transport him to hospital despite his request, misattributing his symptoms to musculoskeletal back pain. Critically, when new symptoms of suprapubic and epigastric pain developed en route to hospital on the second callout, the attending ambulance officer failed to communicate this to the triage nurse. The patient was triaged as category four (2+ hour wait) based only on chronic back pain. He was not fully assessed until discovered to be pale, sweaty, and pulseless on examination in the emergency department cubicle, at which point he was rushed to theatre. He died from uncontrolled haemorrhage from a ruptured aortic aneurysm. Key failures: inadequate physical examination at first attendance, failure to escalate when new abdominal symptoms emerged, and critical handover failure to triage.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- failure to perform adequate physical examination at first ambulance attendance
- failure to take blood pressure measurement despite request, relying on radial pulse alone
- inadequate assessment and dismissal of symptoms as musculoskeletal
- failure to recognise significance of new symptoms (suprapubic and epigastric pain) developing en route to hospital
- failure of ambulance officer to communicate new abdominal pain symptoms to triage nurse at handover
- low triage priority assigned (category 4) based on incomplete handover information
- patient not triaged for imaging or abdominal assessment
- delayed recognition of shock physiology (pallor, sweating, absent pulses) until arrival in ED cubicle
- unsympathetic approach by ambulance officer may have discouraged patient from insisting on hospital transport at first attendance
Coroner's recommendations
- Establish a system whereby the triage assist nurse has responsibility to chase up the patient case card from the ambulance service and ensure it is obtained before the first half-hourly observations are carried out
- If the case card reveals that the triage category was inappropriate, or if the case card together with observations suggest inappropriateness, the nurse assist should alter the triage category or ask the triage nurse to reconsider it
- Ensure that ambulance case cards reliably reach the triage nurse and are reviewed before triage assignment
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