Coroner's Finding: SELBY-FULLGRABE Fiona Louise
Deceased
Fiona Louise Selby-Fullgrabe
Demographics
35y, female
Date of death
2013-05-12
Finding date
2015-09-18
Cause of death
coronary artery dissection
AI-generated summary
Fiona Selby-Fullgrabe, 35, presented to Wallaroo Hospital with chest pain, arm weakness, and diaphoresis. Ambulance noted elevated troponin (121) and activated the chest pain protocol. However, Dr M. discharged her after 1.5 hours, attributing symptoms to a neurological cause based on remote history of similar symptoms several years prior. He failed to follow the iCCnet protocol requiring cardiologist contact and admission. She collapsed at home 8 hours later with coronary artery dissection causing acute coronary occlusion. The coroner found Dr M. made a serious clinical error by allowing young age and female sex to create low index of suspicion for acute coronary syndrome despite objective evidence (elevated troponin, chest pain, syncope, diaphoresis). Had protocol been followed, she would have been admitted, anticoagulated, and had opportunity for angiography with potential stenting, with survival probability estimated at 50-90%.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to follow chest pain protocol (iCCnet)
- failure to admit patient with elevated troponin
- failure to contact on-duty cardiologist
- diagnostic bias based on patient age and sex (young female)
- misattribution of symptoms to neurological cause
- failure of nursing staff to escalate concerns about protocol violation
- inadequate supervision and follow-up by senior doctors
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