Coronial
TAShospital

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. Report an inaccuracy.

Specialties

emergency medicinegeneral practicevascular surgeryoncologyrespiratory medicine

Error types

diagnosticcommunication

Drugs involved

morphineketorolac

Clinical conditions

abdominal aortic aneurysmsmall cell lung cancerhypertensionaortic rupture

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

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