Finding into death of YLM

Contributing factors

• Lack of clarity in Statewide Referral Criteria regarding transient pain and when to refer symptomatic abdominal aortic aneurysms to emergency department
• Radiologist did not directly contact the referring GP to discuss the significant finding of a 7.1cm abdominal aortic aneurysm
• Failure of fax transmission of the referral from the GP practice to Royal Melbourne Hospital vascular surgery outpatient clinic
• Absence of feedback mechanism to the referring doctor regarding receipt or non-receipt of the referral
• GP's decision to refer to outpatient clinic rather than emergency department, influenced by perceived risk of COVID-19 exposure
• Patient's reluctance to present to hospital despite wife's concerns
• Lack of recognition that transient abdominal pain in context of large aneurysm warranted emergency assessment

Coroner's recommendations

1. The Victorian Department of Health consider amending the wording of the Statewide Referral Criteria regarding aortic aneurysms to clarify which patients should be discussed with the vascular registrar or sent to an emergency department, including the significance of transient symptoms.
2. FMIG Imaging remind their radiologists of their obligations to contact referring doctors directly to discuss any significant unexpected, urgent, or critical clinical radiology findings.