Finding into death of Margaret Smith
Deceased
Margaret Smith
Demographics
91y, female
Date of death
2015-03-05
Finding date
2016-08-19
Cause of death
Unascertained
AI-generated summary
Margaret Smith, a 91-year-old admitted with head strike from fall, developed moderate depression during her stay and received electroconvulsive therapy (ECT) as a compulsory patient. On 5 March 2015, she developed epigastric and chest pain in the early hours; Dr O. assessed this as likely reflux or angina, prescribed appropriate medications, and arranged morning follow-up. However, repeat cardiac enzyme testing and ECG at the standard 6-hour post-chest pain interval were not performed, with unclear documentation of the morning medical team review. She was found unresponsive at 10:45 am and declared deceased. The coroner found the overall medical and mental health management reasonable and appropriate, though the missed follow-up investigations represent a potential gap in acute coronary care assessment.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- fall with head strike
- recurrent depressive disorder resistant to medication
- acute renal impairment and metabolic acidosis
- pneumonia
- urinary tract infection
- delirium
- electrolyte derangements
- epigastric/chest pain of unclear aetiology
- missed follow-up cardiac investigations
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