Coroner's Finding: Hoskinson, Neville Robert
Deceased
Neville Robert Hoskinson
Demographics
55y, male
Date of death
2012-05-17
Finding date
2017-03-31
Cause of death
cardiac tamponade resulting from proximal aortic dissection due to hypertension
AI-generated summary
A 55-year-old man presenting with acute severe chest pain, headache and jaw pain to a regional hospital was evaluated for aortic dissection. A CT angiogram was performed but the radiologist's verbal report contained ambiguities and omissions compared to the written report, which mentioned possible mediastinal haemorrhage. Clinicians documented 'no dissection' despite the written report not definitively excluding it. A transthoracic echocardiogram ordered by cardiology was cancelled the next day due to an administrative error, delaying diagnosis by 24 hours. When imaging was resumed, a transoesophageal echocardiogram confirmed dissection but the aorta further dissected during the procedure, causing cardiac tamponade and death. Had diagnosis occurred one day earlier, the patient had a 60% survival prospect.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- delayed diagnosis of aortic dissection
- inadequate communication of CT angiogram findings from verbal report
- cancellation of transthoracic echocardiogram due to administrative error
- absence of immediate written radiological report
- misinterpretation or misrecording of radiology findings by treating clinicians
- delay in transoesophageal echocardiogram due to patient having eaten breakfast
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