Coroner's Finding: CAMERON Louise Cherise

Contributing factors

• failure to perform rectal examination despite clear symptoms of gastrointestinal bleeding
• inadequate assessment of chest pain with only single troponin test and ECG
• failure to obtain serial troponin testing
• inadequate interpretation of abnormal ECG findings (Q waves, anterior myocardial infarction notation)
• premature discharge without admission despite red flag symptoms
• inadequate senior medical supervision of first-year medical officer
• chronic anaemia predisposing to myocardial infarction
• gastric vascular ectasia causing upper gastrointestinal bleeding and hypotension

Coroner's recommendations

1. The coroner drew attention to the protocol 'Management of Chest Pain/Suspected Acute Coronary Syndrome' produced by Professor Kelly, commenting it seems eminently sensible and could be readily deployed at Noarlunga Health Service Emergency Department. The coroner noted that steps have already been taken as a consequence of the death, including review of chest pain assessment processes, clarification of senior doctor expectations, increased emergency physician support with improved supervision of junior staff, comprehensive education programme for junior doctors, and monthly morbidity and mortality meetings in ED.