Finding into death of Mr C
Deceased
Mr C
Demographics
56y, male
Date of death
2020-02-18
Finding date
2021-10-23
Cause of death
Ischaemic Heart Disease and Coronary Artery Atherosclerosis
AI-generated summary
A 56-year-old man with a history of coronary artery disease and stenting presented to his GP on 17 February 2020 with right upper quadrant discomfort. The GP did not consider a cardiac source, attributing symptoms to abdominal pathology. The patient died suddenly the following day from a fatal cardiac arrhythmia due to severe triple-vessel coronary artery atherosclerosis. While the coroner found the GP's care met reasonable standards, a missed opportunity existed to consider cardiac causes despite atypical presentation. Key lessons: maintain high index of suspicion for ischaemic heart disease in at-risk patients even with atypical symptoms; document clinical reasoning thoroughly; ensure vital signs monitoring; recall patients for recommended cardiac surveillance. The coroner emphasised importance of thorough history-taking and patient education regarding symptom thresholds for seeking emergency care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Severe triple-vessel coronary artery atherosclerosis
- Myocardial fibrosis
- Evidence of previous myocardial infarction
- Missed opportunity to consider cardiac aetiology for atypical presentation
- Lack of recall system for recommended stress echocardiography
- Vital signs not taken at final consultation
- Inadequate clinical documentation of decision-making
Coroner's recommendations
- General Practitioners should consider past medical history and cardiac risk factors when patients present with atypical discomfort or pain
- General Practitioners should take and document thorough history regarding the nature of presenting symptoms
- Advice to patients to have a low threshold for seeking further medical attention if symptoms persist, especially where diagnosis is not clearly evident
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —