Coroner's Finding: Ridgeon Beryl Jean
Deceased
Beryl Jean Ridgeon
Demographics
83y, female
Date of death
2019-12-17
Finding date
2020-11-23
Cause of death
haemopericardium due to ruptured acute myocardial infarction with underlying coronary atherosclerosis
AI-generated summary
An 83-year-old woman presented to Mersey Community Hospital with vomiting and suspected gastroenteritis. An ECG was performed as a routine process and clearly demonstrated acute ST-elevation myocardial infarction (STEMI), but this critical finding was missed by clinical staff. She was discharged with anti-nausea medication. She died at home the following day from haemopericardium secondary to rupture of acute myocardial infarction. The coroner found that diagnostic anchoring to gastroenteritis prevented consideration of acute coronary syndrome, and that the ECG was not formally reviewed by senior clinicians. Proper ECG interpretation and consideration of differential diagnoses could have prevented this death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- diagnostic anchoring to gastroenteritis diagnosis
- failure to consider differential diagnoses including acute coronary syndrome
- ECG not formally ordered but performed as routine process
- ECG not formally reviewed or interpreted by senior clinician
- failure to recognise ST-elevation myocardial infarction on ECG
- inappropriate discharge without cardiac investigation despite ECG abnormality
Coroner's recommendations
- All ECGs should be reviewed, interpreted and signed off by the senior clinician on the floor
- Staff at Mersey Community Hospital should receive appropriate training in how to interpret ECG results
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