Deceased
Wayne Brian Mitchell
Demographics
49y, male
Date of death
2015-11-16
Finding date
2018-07-12
Cause of death
ischaemic heart disease with coronary artery thrombosis (left main stem coronary artery occlusion)
AI-generated summary
Wayne Mitchell, a 49-year-old man, presented to a clinic with acute chest pain radiating to his jaw, accompanied by dizziness, diaphoresis, and dyspnoea. His symptoms resolved before ambulance arrival. The paramedics performed a normal ECG and transported him to a primary care clinic rather than hospital. Dr V. assessed Mitchell as low-risk for myocardial infarction without repeating the ECG or establishing a working diagnosis. When troponin results returned at 45 ng/L (elevated), Dr V. misinterpreted the pathology report and took no action, failing to apply the chest pain protocol. Mitchell died that evening from left main stem coronary artery occlusion with thrombosis. Expert evidence indicated that timely recognition of the elevated troponin, repeat ECG, hospital admission, and cardiology involvement would have likely prevented his death. This case highlights the critical importance of applying acute coronary syndrome protocols regardless of symptom resolution, correctly interpreting troponin results, and maintaining a low threshold for hospital referral in patients with risk factors and typical ACS symptoms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
30y · Male·Unascertained; likely cardiac arrhythmia
Adam Troy Shepley, aged 30, died in police custody following restraint after climbing onto roofs while displaying drug-affected and paranoid behaviour. Post-mortem examination revealed an unascertained cause, likely a ca…
30y · Female·tricuspid valve bacterial endocarditis
Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.