Coroner's Finding: Holden, Richard Arthur
Deceased
Richard Arthur Holden
Demographics
74y, male
Date of death
2020-08-29
Finding date
2026-08-21
Cause of death
Pulmonary thromboembolism due to right deep vein thrombosis
AI-generated summary
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond to treatment over repeated visits. Post-mortem revealed massive pulmonary thromboembolism from right deep vein thrombosis. The coroner found Dr C. suffered from diagnostic commitment bias—continuing asthma treatment without considering serious differential diagnoses, particularly pulmonary embolism. Expert evidence indicated hospital referral or doppler ultrasound was mandated by 28 August 2020. The coroner found the death preventable if appropriate referral had been made on that date. Dr C. had mistakenly believed PE always presents with chest pain. The coroner recommended raising awareness among GPs about subtle presentations of pulmonary embolism and diagnostic commitment bias following treatment failure.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Diagnostic commitment bias to asthma diagnosis
- Failure to consider differential diagnoses despite escalating symptoms
- Failure to refer to hospital or for imaging on 28 August 2020
- Misapprehension that pulmonary embolism always presents with chest pain
- Continued asthma treatment without reassessment despite lack of response to therapy
- Varicose veins noted but not connected as risk factor for thromboembolism
Coroner's recommendations
- A communique be sent to the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine drawing attention to this finding and raising awareness of the subtlety with which pulmonary embolism can present. Members should be reminded to first consider and exclude diagnoses of very high risk and be alert to the potential for diagnostic commitment bias following a failure to improve with treatment.
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