Deceased
Adelaide Wilson
Demographics
86y, female
Coroner
Coroner Simon McGregor
Date of death
2022-02-07
Finding date
2024-04-08
Cause of death
Cardiogenic shock
AI-generated summary
Adelaide Wilson, 86 years old, presented to an urgent care centre with two days of chest pain and vomiting. A point-of-care troponin test (i-STAT) returned 0.4 ng/L, interpreted as normal, and she was discharged with gastritis. She deteriorated the next day with cardiogenic shock and died at Austin Hospital. The Austin's troponin was 329 ng/L, confirming type-II myocardial infarction. The i-STAT result was actually elevated but misinterpreted because the device printout lacked reference ranges. Critical failures included: abnormal vital signs not escalated to medical staff, no documented differential diagnosis or risk stratification, no clear responsibility for result validation, and delayed result review (12 days later). While earlier recognition may not have prevented death given her age and comorbidities, system improvements were recommended: providing reference ranges on point-of-care devices, flagging abnormal vital signs electronically, staff education on chest pain assessment, and dual checking of results.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
61y · Male·Intracranial haemorrhage and myocardial infarct
A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…
58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis
Michael Burns, 58, presented to hospital with exertional chest pain and shortness of breath. He was diagnosed with stable angina and discharged home on cardiac medications. He returned the next day with dizziness attribu…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
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