Coronial
VIChospital

Finding into death of Elizabeth Mary Gorman

Deceased

Elizabeth Mary Gorman

Demographics

35y, female

Coroner

Coroner Peter White

Date of death

2012-09-05

Finding date

2018-09-27

Cause of death

Pulmonary thromboembolus and pulmonary infarction

AI-generated summary

A 35-year-old woman at 11 weeks gestation presented to Royal Women's Hospital Emergency Care on 3 September 2012 with chest and rib pain following severe vomiting. Dr M., a junior resident working alone overnight, assessed her as musculoskeletal pain and discharged her without ECG or imaging. She returned 17 hours later in near-cardiac collapse with massive bilateral pulmonary emboli and died despite thrombectomy. The coroner found Dr M.'s assessment insufficiently thorough—PE should have been more actively excluded through basic investigations (ECG, chest X-ray). Systemic failures included inadequate emergency medicine supervision, lack of guidelines requiring ECG for chest pain, and barriers to accessing senior advice. Ambulance paramedics also erred by transporting her to RWH rather than RMH, contrary to time-critical protocols.

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

Specialties

emergency medicineobstetricscardiothoracic surgeryparamedicine

Error types

diagnosticcommunicationsystemdelay

Drugs involved

oxycodoneintravenous fluids

Clinical conditions

pulmonary embolismdeep vein thrombosishyperemesis gravidarumpregnancychest painrib painshocktachycardia

Procedures

electrocardiogramultrasoundthrombectomycardiopulmonary bypassextracorporeal membrane oxygenation

Contributing factors

  • Failure to perform ECG at initial presentation
  • Inadequate differential diagnosis exploration for pulmonary embolism
  • Junior resident working alone overnight without adequate supervision
  • Absence of emergency medicine-specific training for Dr M.
  • No guideline requiring ECG for chest/rib pain at RWH in 2012
  • Barriers to accessing senior medical advice
  • Ambulance decision to transport to RWH rather than RMH despite time-critical presentation
  • Paramedic misinterpretation of possible ectopic pregnancy as basis for RWH destination
  • MICA clinician error in decision-making regarding hospital destination
  • Inadequate communication of vital signs to receiving hospital
  • Lack of inter-hospital coordination for time-critical patients
  • Hyperemesis gravidarum and associated immobility as VTE risk factors not adequately weighted

Coroner's recommendations

  1. Directors of Emergency Services at RWH and RMH together with Ambulance Victoria should meet under guidance of the Secretary of the Department of Health and Human Services to consider feasibility of a single triage point at RMH to determine whether female patients should be admitted to RWH (WEC) or RMH
  2. Establish formal guidelines requiring ECG for all patients presenting with chest/rib pain to WEC
  3. Improve senior medical supervision and support structure for junior residents working overnight in the WEC
  4. Provide formal induction and emergency medicine training for medical staff rotating through the WEC
  5. Establish clear protocols for junior doctors to access senior emergency medicine advice
  6. Improve inter-hospital communication and coordination between RWH and RMH for time-critical patients
  7. Clarify Ambulance Victoria protocols to emphasize that time-critical patients with unclear diagnosis should be transported to hospitals with full emergency resuscitation capabilities
  8. Establish direct communication between paramedics and receiving hospitals during transport
  9. Review and update hospital capabilities information provided to Ambulance Victoria clinicians
Full text
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Source and disclaimer

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