Coroner's Finding: Patrick, Robert David
Deceased
Robert David Patrick
Demographics
65y, male
Date of death
2016-10-16
Finding date
2018-09-21
Cause of death
ruptured abdominal aortic aneurysm
AI-generated summary
A 65-year-old man with recently diagnosed small cell lung cancer presented to a rural hospital with acute back pain. He had a known abdominal aortic aneurysm (73mm) identified on staging scans. The attending nurse documented elevated blood pressure (195/110) and the aneurysm history, but this critical information was not communicated to the on-call doctor. The doctor diagnosed musculoskeletal back strain from lifting equipment and prescribed ketorolac. The patient was discharged; he died at home the following morning from ruptured aortic aneurysm. The coroner found that while correct diagnosis at the hospital would have been reasonable if the doctor had reviewed the full clinical picture including blood pressure and aneurysm history, the logistical challenges of transferring a patient from a remote location to the only facility capable of emergency aortic surgery made survival unlikely even with correct diagnosis.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- failure to communicate critical clinical information (elevated blood pressure and aortic aneurysm history) from nurse to doctor
- on-call doctor did not attend in person to assess patient
- misdiagnosis of acute aortic aneurysm rupture as musculoskeletal back strain
- remote hospital location with limited surgical capability
- logistical delays in accessing definitive care at tertiary facility
Full text
Related cases
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 —