Coronial
TAScommunity

Coroner's Finding: de-identified FG

Demographics

53y, male

Date of death

2023-04-10

Finding date

2025-04-24

Cause of death

Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis of the left anterior descending coronary artery

AI-generated summary

A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made, and an exercise stress test (November 2022) showed equivocal results suggestive of ischaemia. An echocardiogram in February 2023 revealed abnormal left ventricular wall motion indicating coronary artery disease. However, instead of urgent coronary angiography, a CTCA was ordered, which was cancelled. The patient died of acute myocardial infarction in April 2023. The coroner found that coronary angiography should have been pursued urgently following the abnormal echocardiogram. Delays in diagnostic pathway and access to interventional cardiology services were contributing factors. The patient's reluctance to attend appointments and commence medications also played a role.

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

Specialties

cardiologygeneral practicepathology

Error types

diagnosticdelay

Drugs involved

rosuvastatinatorvastatinaspirinmetoprololisosorbide

Clinical conditions

coronary artery diseaseacute myocardial infarctionexertional anginatriple vessel atherosclerosisleft anterior descending coronary artery thrombosisleft ventricular hypokinesiahypertensionhyperlipidaemiaobesity

Procedures

exercise stress testechocardiogramcoronary artery calcium score CT scan

Contributing factors

  • Delayed diagnosis of coronary artery disease
  • Delay in pursuing coronary angiography following abnormal echocardiogram
  • Ordering of CTCA screening test instead of proceeding directly to coronary angiography
  • Cancellation of CTCA referral with no documented reason
  • Access difficulties to coronary angiography in north-west Tasmania
  • Failure to convey urgency of cardiac disease to patient
  • Patient reluctance to undergo investigations and attend appointments
  • Patient non-adherence to prescribed medications
  • Hypertension
  • Hyperlipidaemia
  • Obesity
Full text

Source and disclaimer

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