Finding into death of Stuart Judd
Deceased
Stuart MacPherson Judd
Demographics
39y, male
Coroner
Coroner F Hayes
Date of death
2006-07-30
Finding date
2011-03-17
Cause of death
Ischaemic heart disease with complete occlusion of the left anterior descending coronary artery with ruptured plaque and recent thrombosis. Recent myocardial infarction of 24-48 hours duration.
AI-generated summary
Stuart Judd, a 39-year-old Parks Victoria Ranger, died of acute myocardial infarction due to left anterior descending coronary artery occlusion with ruptured plaque. Eight days before death, he presented to GP Dr V. with chest pain on exertion (cycling, chopping wood) and arm heaviness. The doctor diagnosed reflux oesophagitis, ordered ECG and troponin testing (both normal at 3.5 hours post-symptom onset), and prescribed Losec. The coroner found that while initial acute MI exclusion was reasonable, failure to investigate for angina with stress ECG was suboptimal management. The troponin test timing was premature (recommended ≥4 hours post-event), and stress testing would likely have identified ischaemic heart disease. Early diagnosis could have prevented death. Poor documentation of examination findings was also identified.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Failure to investigate for angina pectoris despite atypical but concerning chest pain presentation
- Failure to order stress ECG when indicated by symptoms of exertional chest pain
- Premature timing of troponin testing (3.5 hours post-symptom onset rather than standard 4 hours or repeat testing)
- Diagnosis anchored on reflux oesophagitis without adequately excluding cardiac disease
- Deficient medical documentation of examination findings (cardiac, gastrointestinal)
- Inadequate follow-up plan; patient discharged with reliance on future review rather than urgent cardiac investigation
Coroner's recommendations
- General practitioners should record in their notes both positive and negative findings from consultations.
Full text
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