Deceased
James Pickup
Demographics
59y, male
Date of death
2015-10-26
Finding date
2018-04-26
Cause of death
Pulmonary embolus
AI-generated summary
A 59-year-old man with obesity, smoking history, hypertension, and hypercholesterolaemia presented to the ED with two days of acute onset shortness of breath. The registrar diagnosed COPD based on normal vitals, clinical examination, normal ECG, and chest X-ray showing increased lung volumes. The patient was discharged with outpatient follow-up. He died at home the next day; autopsy revealed massive pulmonary embolism. The coroner found that while COPD was a reasonable diagnosis, the sudden onset of dyspnoea without prior COPD history should have triggered broader differential diagnosis consideration including PE. The registrar failed to apply risk stratification tools (Wells score/PERC rule) or seek senior consultation. The coroner identified this as a missed diagnostic opportunity and emphasised the importance of maintaining broad differential diagnosis in acute presentations, seeking consultant input, and developing clinical gestalt through experience.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
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