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Coroner's Finding: Lukacevich, Anton

Deceased

Anton Lukacevich

Demographics

64y, male

Date of death

2022-01-25

Finding date

2023-08-18

Cause of death

coronary atherosclerosis with early myocardial infarction

AI-generated summary

A 64-year-old man suffered acute myocardial infarction at home. His wife called triple-0 at 10:34 am reporting classic cardiac symptoms: sudden sweating, shortness of breath, and shoulder pain. The emergency dispatch system incorrectly categorised the call as 'less apparent priority', and no ambulance was sent. A second call at 12:00 pm found him collapsed, unresponsive, and blue. Despite CPR by family, he died before paramedics arrived. Autopsy confirmed coronary atherosclerosis with early MI. The coroner found the failure to appropriately prioritise the initial call was 'non-compliant call taking' that potentially cost the patient a chance of survival. Key lesson: dispatch systems must reliably recognise classic acute coronary syndrome presentations to ensure timely ambulance response.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologyemergency medicineparamedicine

Error types

systemcommunicationdelay

Clinical conditions

acute myocardial infarctioncoronary atherosclerosis

Contributing factors

  • incorrect prioritisation of emergency call in Medical Priority Dispatch System
  • non-compliant call taking by Ambulance Tasmania
  • failure to recognise classic cardiac symptoms and appropriate urgency
  • delay in ambulance dispatch

Coroner's recommendations

  1. Ambulance Tasmania should review its Medical Priority Dispatch System to ensure correct categorisation of acute coronary syndrome presentations
  2. Improved training and compliance monitoring of call-taking staff to recognise classic cardiac symptoms requiring immediate ambulance dispatch
Full text

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