Deceased
Beverley Joy Coats, Heather Maud West, Lorna Margaret D'Souza
Demographics
female
Date of death
2016-08-02, 2017-05-02, 2019-05-27
Finding date
2023-03-01
Cause of death
haemopericardium due to aortic dissection (all three cases)
AI-generated summary
Three elderly women died from acute aortic dissection at Queen Elizabeth Hospital, South Australia. Beverley Coats (73) presented three times in July 2016 with back pain, nausea and vomiting; her known aortic dilatation was not documented in electronic records. Her death was not preventable due to high surgical mortality (60-70%) and comorbidities. Heather West (79) presented with chest pain radiating to back in May 2017 and was discharged after ACS protocol ruled out heart attack; aortic dissection was not considered despite classic symptoms, and would likely have been preventable with earlier diagnosis (5-10% surgical mortality). Lorna D'Souza (81) presented with chest and jaw pain in May 2019; aortic dissection was not suspected and she was discharged after 3.5 hours without investigation. Key failures included: aortic dissection absent from ACS pathways, lack of senior review, incomplete clinical information on imaging requests, delayed radiologist review, and failure to consider differential diagnoses when troponin was negative. These deaths highlight the need for explicit consideration of aortic dissection in chest pain evaluation protocols.
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Specialties
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