Deceased
Goet Wo Tjoeng
Demographics
71y, female
Coroner
Coroner Audrey Jamieson
Date of death
2015-07-22
Finding date
2017-02-23
Cause of death
aortic dissection (Stanford Type A)
AI-generated summary
A 71-year-old woman presented to hospital with pericardial effusion causing cardiac tamponade, successfully treated by pericardiocentesis. The underlying cause was a Stanford Type A aortic dissection, which was not identified during life despite a CT angiogram being performed. The CT images were suboptimal due to poor cardiac output and could not adequately exclude dissection, but this critical limitation was not clearly communicated from radiology to cardiology. A consultant radiologist's amendment recommending repeat CT imaging with ECG gating was apparently not acted upon. The treating team did not fully reconsider aortic dissection as a cause of the haemopericardium on 21 July. The coroner found inadequate communication between specialties meant a diagnostic opportunity was missed, though acknowledged that even with earlier diagnosis, surgical outcome would have been uncertain given the patient's age and risk profile.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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Michael Burns, 58, presented to hospital with exertional chest pain and shortness of breath. He was diagnosed with stable angina and discharged home on cardiac medications. He returned the next day with dizziness attribu…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
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