Coronial
TAShospital

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.

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
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —