Coroner's Finding: Gordon, Mark Alexander
Deceased
Mark Alexander Gordon
Demographics
51y, male
Date of death
2015-03-22
Finding date
2016-06-20
Cause of death
Pericardial tamponade complicating Type I aortic dissection in the setting of long-standing hypertensive cardiovascular disease
AI-generated summary
Mark Gordon, 51, presented to Royal Hobart Hospital Emergency Department on 20 March 2015 with sudden onset chest pain. Initial assessment suspected acute coronary syndrome with elevated troponin. Over 36 hours he experienced multiple warning signs: unwitnessed syncope, light-headedness, pain radiating to his back, and pleuritic chest pain. Despite these classic signs of aortic dissection, no such diagnosis was considered by the medical team, including a consultant physician. No CT imaging was obtained. The patient arrested on 22 March and died. Autopsy revealed Type I aortic dissection with pericardial tamponade. The coroner found the diagnosis should have been considered, especially after back pain and syncope developed, and criticized the medical staff for failing to recognize this life-threatening condition. Early imaging and surgery offered approximately 65% chance of survival.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Essential hypertension
- Type II diabetes mellitus
- Morbid obesity (BMI 48)
- Hepatic steatosis
- Chronic thyroiditis
- Failure to consider aortic dissection in differential diagnosis
- Failure to recognize clinical signs of aortic dissection (back pain, syncope, variable pain)
- Absence of imaging investigation (CT scan)
Full text
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