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