Coroner's Finding: Howard, Noeline Dawn
Deceased
Noeline Dawn Howard
Demographics
76y, female
Date of death
2017-06-30
Finding date
2020-08-11
Cause of death
pulmonary embolism due to carcinomatosis
AI-generated summary
A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carcinomatosis) with multiple pulmonary emboli. A CTPA was requested but could not be performed because she was unable to lie flat; no alternative investigation such as ECG was documented. Prophylactic anticoagulation was delayed until day 3. She deteriorated acutely on day 6 and died despite resuscitation. The coroner found there was a significant delay in reaching the correct diagnosis and initiating appropriate treatment. A respiratory specialist opined that earlier accurate diagnosis and treatment may have improved short-term outcome, though uncertainty remains about whether it would have changed the final result.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- delay in reaching correct diagnosis
- failure to diagnose multiple pulmonary emboli
- failure to diagnose underlying carcinomatosis
- initial misdiagnosis as community-acquired pneumonia
- initial misdiagnosis as pulmonary oedema
- delayed initiation of anticoagulation therapy
- failure to perform alternative investigation when CTPA could not be completed
- inability to lie flat preventing CTPA completion
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