Coroner's Finding: Dent, Freda Lillian Florence
Deceased
Freda Lillian Florence Dent
Demographics
85y, female
Date of death
2016-09-22
Finding date
2018-10-30
Cause of death
ischaemic heart disease due to stenosis of coronary bypass grafts
AI-generated summary
An 85-year-old woman with significant cardiac history (prior coronary artery bypass graft) presented with gastrointestinal symptoms. Her GP ceased rosuvastatin without direct communication to nursing staff. Care staff identified symptoms 5 hours later but failed to implement appropriate monitoring of vital signs and fluid balance. Communication with ambulance was poor and lacked urgency; critical delay occurred in the second call timing. Autopsy revealed blocked coronary bypass graft causing acute myocardial infarction. While preventability is uncertain given her severe cardiac disease, key failings included: absence of nursing staff at GP consultation, no documented action plan for close observation, delayed recognition of symptoms, poor fluid monitoring, and inadequate ambulance communication. Earlier vital sign assessment and clearer escalation protocols could potentially have improved outcomes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- absence of nursing staff during GP consultation
- lack of direct communication between GP and nursing staff regarding care plan
- no documented action plan for close observation and vital sign monitoring
- delayed recognition of patient symptoms (5 hours after GP visit)
- inadequate recording and monitoring of fluid intake and output
- poor communication with ambulance service
- lack of urgency conveyed in first ambulance call
- incorrect documentation of ambulance call timing
- failure to escalate clinical deterioration in timely manner
Full text
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