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Coroner's Finding: Newett, Margaret Wynne

Deceased

Margaret Wynne Newett

Demographics

77y, female

Date of death

2014-01-05

Finding date

2016-04-21

Cause of death

combined effects of ischaemic heart disease and calcific aortic valve sclerosis

AI-generated summary

Margaret Wynne Newett, 77, had moderate aortic stenosis diagnosed in 2011 but was never monitored with follow-up echocardiography as guidelines recommend. On 30 December 2013, she collapsed in a supermarket. At West Coast District Hospital, her ECG was abnormal but a cardiology registrar advised deferring troponin testing and arranging outpatient echocardiogram rather than urgent transfer to Royal Hobart Hospital's cardiac unit. She was discharged, collapsed again on 4 January, and was admitted to North West Regional Hospital with confirmed myocardial infarction and severe ischaemic changes. She developed atrial fibrillation, arrested and died. The coroner found her death possibly preventable if her serious condition and syncope presentation had prompted urgent referral and cardiac assessment. Key failures included: no follow-up echocardiography post-diagnosis, incomplete ECG interpretation, failure to test troponin acutely, and the registrar's non-escalation of a critical situation. Recommendations were formal telephone advice protocols and annual cardiology review for aortic stenosis patients.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiologygeneral practiceemergency medicine

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

aortic stenosisischaemic heart diseasesyncopemyocardial infarctioncalcific aortic valve sclerosis

Procedures

echocardiogramelectrocardiogramtroponin testing

Contributing factors

  • failure to perform follow-up echocardiography within 2 years as recommended by guidelines
  • inadequate interpretation of ECG by cardiology registrar
  • failure to perform troponin testing on 30 December 2013
  • failure to recognize syncope in context of known aortic stenosis as indication for urgent transfer to cardiac center
  • inadequate telephone advice protocols for communication between regional hospitals and tertiary cardiology
  • lack of continuity of care in rural setting with short-stay practitioners
  • delayed referral process after syncope

Coroner's recommendations

  1. The Launceston General Hospital should adopt protocols for telephone advice to outlying health facilities, including: (1) keeping written records of communications; (2) requiring a consultant to be informed of advice provided by non-consultant staff at first opportunity; (3) requiring that ECGs be reported upon by a consultant.
  2. The State health authority should consider adopting a practice whereby all patients diagnosed with moderate to severe aortic stenosis are referred to the cardiology unit at the Royal Hobart Hospital for annual review of their condition.
Full text
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