Coroner's Finding: CANDY Jonathon Craig
Deceased
Jonathon Craig Candy
Demographics
42y, male
Date of death
2010-05-20
Finding date
2013-01-31
Cause of death
ischaemic heart disease due to coronary atherosclerosis
AI-generated summary
Jonathon Candy, aged 42, died from acute coronary syndrome one day after inappropriate discharge from Queen Elizabeth Hospital ED. He presented with recurrent chest pain on exertion (gym evening of 18 May, workplace morning of 19 May) with prior stent history. Critical communication and history-taking failures occurred: triage notes were inaccurate, nurse Wu misinterpreted timing of pain episodes, and Dr N. failed to obtain complete history despite paramedic documentation of morning chest pain. ECG showed nonspecific changes; troponin was normal but single test insufficient given symptom timing. Expert evidence established that proper history-taking would have mandated repeat ECG and troponin testing before discharge. Angioplasty would have offered 95% one-year survival. Death was entirely preventable through adherence to standard cardiac assessment protocols and communication of critical clinical information.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- failure to obtain complete and accurate history
- miscommunication about timing of chest pain episodes
- inaccurate triage documentation
- failure to review ambulance service patient report form
- inadequate ECG interpretation
- single troponin test insufficient given symptom timeline
- failure to escalate for cardiology review despite cardiac history and abnormal ECG computer interpretation
- discharge without repeat investigation
Full text
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