Coroner's Finding: Barnett Catherine Diana
Deceased
Catherine Diana Barnett
Demographics
55y, female
Date of death
2021-03-13
Finding date
2021-12-13
Cause of death
acute myocardial infarction due to right coronary artery thrombosis
AI-generated summary
A 55-year-old woman presenting to the emergency department with 24 hours of chest pain, arm pain, sweating and vomiting was discharged without an ECG or troponin measurement. She had an abdominal CT suggesting cholecystitis, but the coroner's medical advisor noted that her symptoms strongly indicated possible acute coronary syndrome, particularly given her smoking history. She returned three days later in shock and suffered fatal cardiac arrest from acute myocardial infarction due to right coronary artery thrombosis. The key clinical lesson is that chest pain with typical features of acute coronary syndrome requires ECG and troponin testing regardless of alternative diagnoses; these investigations are non-invasive and essential for risk stratification in smokers presenting with concerning symptoms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- failure to perform ECG on presentation
- failure to measure troponin levels
- misattribution of symptoms to abdominal pathology
- inadequate risk stratification in smoker with chest pain
- premature discharge without ruling out acute coronary syndrome
Full text
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