Coroner's Finding: Helen Mary Badcock
Deceased
Helen Mary Badcock
Demographics
77y, female
Date of death
2020-12-26
Finding date
2021-11-29
Cause of death
haemoperitoneum and retroperitoneal haematoma secondary to Type I aortic dissection
AI-generated summary
Helen Mary Badcock, 77, presented to Launceston General Hospital on Christmas Day 2020 with abdominal pain and right leg numbness. Ambulance paramedics documented inability to obtain blood pressure on her right arm—a critical clinical sign of aortic dissection. Hospital staff failed to recognise this finding or perform proper cardiovascular examination. A CT spine was ordered for degenerative disc disease, and she was discharged with painkillers. She died the following evening from Type I aortic dissection with haemoperitoneum. The coroner found care fell below acceptable standard due to failure to recognise blood pressure differential between arms (>20 mmHg difference has 28% probability of dissection) and absence of documented cardiovascular examination. Early recognition and imaging (CT angiography) with urgent cardiothoracic surgery could have been life-saving.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
Contributing factors
- failure to recognise blood pressure differential between arms
- inadequate cardiovascular examination
- failure to consider aortic dissection in differential diagnosis
- absence of documentation of bilateral blood pressure measurements
- absence of pulse deficit assessment
- inappropriate attribution of symptoms to spinal degenerative disease
- missed opportunity for imaging with CT angiography
Full text
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