Coroner's Finding: DALLING Brian Terrance and SALOTTI Jack William and GRZYWACZ Richard John and SOBEY Brian Leslie

Contributing factors

• failure to recognise acute coronary syndrome presentation
• inadequate risk factor assessment
• failure to perform immediate ECG
• failure to obtain or consider previous abnormal ECG results
• inadequate ECG interpretation
• failure to repeat ECG and troponin testing
• failure to seek specialist ECG interpretation
• over-reliance on single negative troponin test
• failure to follow iCCNet protocols
• discharge from hospital without repeat testing
• patients not fully informed of risks
• failure to escalate to tertiary care
• lack of awareness of iCCNet services
• alternative explanations leading to dismissal of cardiac aetiology
• partial symptom resolution mistaken for benign cause

Coroner's recommendations

1. Minister for Health to establish training programs for general practitioners, especially those in country areas, on: importance of examining patient risk factors for heart disease; conducting global risk assessment considering risk factors and symptomatology together; respecting paramedic observations; obtaining previous patient records including ECGs; studying and understanding iCCNet protocols and National Heart Foundation guidelines; rigorously following acute coronary syndrome diagnostic pathways to conclusion; considering worst-case scenarios for chest pain presentations; developing greater knowledge and skill in ECG interpretation; comparing ECGs within series to identify changes; knowing when to refer ECGs for specialist interpretation; providing patients with sufficient information for informed decisions; understanding pathophysiology of acute coronary syndrome
2. Clinical Director of iCCNet to amend Management of Chest Pain/Suspected Acute Coronary Syndrome protocol to include: emphasis that single negative ECG and troponin results do not exclude acute coronary syndrome; importance of examining for ECG changes within series of ECGs; appropriate occasions for expert specialist ECG referral
3. Royal Australian College of General Practitioners and Royal Australian College of Rural and Remote Medicine to include in curricula more rigorous training on acute coronary syndrome identification with emphasis on ECG interpretation, identifying changes in ECG series, utility and timing of troponin levels, and include these topics in examination materials
4. Minister for Health to advise general practitioners to highlight risk factors for heart disease prominently in individual patient records
5. Minister for Health to maintain careful scrutiny of expertise and knowledge of overseas-trained medical practitioners regarding acute coronary syndrome identification and ECG interpretation skills