Deceased
Ivanka Kresevic
Demographics
74y, female
Date of death
2017-01-09
Finding date
2021-11-16
Cause of death
acute myocardial infarction due to coronary artery thrombosis
AI-generated summary
74-year-old woman presented to emergency department with chest pain on 6 January 2017. She was diagnosed with gastro-oesophageal reflux disease and discharged after 53 minutes. She died of acute myocardial infarction due to coronary artery thrombosis three days later. Key failures: the resident medical officer (Dr V.) did not include acute coronary syndrome in differential diagnosis despite intermediate-risk presentation with exertional burning chest pain and diaphoresis; he was unaware of or did not act on a pain score of 7/10; troponin testing was not ordered despite symptoms consistent with ACS; consultation with consultants was not documented, and whether they were fully appraised of the presentation is unclear. Expert cardiology evidence confirmed troponin testing would likely have shown abnormality, leading to admission, angiography, and stent placement with excellent prognosis. Death was preventable with appropriate ACS workup and admission.
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Specialties
Error types
Clinical conditions
Procedures
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