A 75-year-old man with hypertension, diabetes, and smoking history presented to a regional emergency department with right lower quadrant abdominal pain, back pain, groin pain, nausea, and vomiting. He was diagnosed with musculoskeletal pain and discharged. He collapsed shortly after leaving and died from a ruptured abdominal aortic aneurysm. While the death was not preventable due to the time constraints of diagnosis and transfer to vascular surgery, there was a missed diagnostic opportunity. The clinical red flags—sudden onset pain not related to movement, repeated vomiting, and high-risk patient demographics—were not recognised. The coroner found this represented a missed opportunity to consider aortic pathology, though even with diagnosis, transfer to a vascular centre would likely have taken too long.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
regional centre without vascular surgery capability
time constraints in diagnosis and transfer
Coroner's recommendations
To Bairnsdale Regional Health Service: Mr Jones' case should be used for educational purposes as a case study for Emergency Department staff.
To Safer Care Victoria: Consider whether further guidance is required to clarify the types of events (such as misdiagnosis leading to patient harm) that should be reported as adverse patient safety events and registered with the Victorian Health Incident Management System.
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