Coroner's Finding: CAMERON Louise Cherise
Deceased
Louise Cherise Cameron
Demographics
32y, female
Date of death
2008-05-12
Finding date
2010-10-25
Cause of death
ischaemic heart disease complicated by upper gastrointestinal haemorrhage
AI-generated summary
A 32-year-old woman with schizophrenia presented to the emergency department with chest pain radiating to both arms, profuse sweating, and vomiting black material for several days. She also reported black stools. The first-year medical officer and senior doctor diagnosed oesophagitis, ordered morphine, and discharged her after ~2 hours with a single troponin test and ECG. She died the next day from acute coronary thrombosis complicated by upper gastrointestinal haemorrhage. Critical omissions included: failure to perform a rectal examination despite clear signs of gastrointestinal bleeding (black chunks in stool/vomit); failure to obtain serial troponin tests (only one test at admission); and inadequate interpretation of the abnormal ECG showing Q waves suggesting prior cardiac damage. Had either condition been detected—particularly the GI bleed via rectal examination—hospital admission would have occurred, potentially preventing death. Supervision and protocols for chest pain assessment were inadequate.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
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
- 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.
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