Finding into death of Goet Wo Tjoeng
Deceased
Goet Wo Tjoeng
Demographics
71y, female
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.
Error types
Clinical conditions
Contributing factors
- suboptimal CT imaging due to poor cardiac output
- inadequate communication of imaging limitations from radiology to cardiology
- lack of clarity in radiology registrar's report conclusion regarding exclusion of aortic dissection
- failure to act on consultant radiologist's amendment recommending repeat CT with ECG gating
- cardiology team did not fully review the complete radiology report or images
- insufficient reconsideration of aortic dissection as cause of haemopericardium on 21 July
Coroner's recommendations
- The Royal Australian and New Zealand College of Radiologists should utilise this case in education regarding report writing, inclusion of all important information in report conclusions, and communication with treating doctors
- Western Health should conduct a review of its 'Provision of Medical Imaging Reports' procedure to ensure clarity about the need to include references to further imaging or investigations in the conclusion of diagnostic imaging reports
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