Finding into death of Susanne Keating
Deceased
Susanne Keating
Demographics
64y, female
Date of death
2021-03-07
Finding date
2026-08-21
Cause of death
Presumed massive pulmonary embolus
AI-generated summary
Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as differential diagnosis and ordered appropriate investigations: CTPA, blood tests (D-dimer, troponin), and ECG. However, these critical tests were not performed during her 6-hour ED stay due to overcrowding, lack of available SCOVID isolation beds, and staffing shortages. She left undiagnosed and attended St John of God Hospital, where she suffered cardiac arrest and died of presumed massive PE within one hour. The coroner found individual clinicians were not criticized, but earlier testing might have prevented death. Key system failures included ED overcrowding, understaffing, and insufficient assessment spaces contributing to diagnostic delay. The coroner recommended Barwon Health staff UHG ED to minimum ACEM standards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Clinical conditions
Procedures
Contributing factors
- Delayed diagnosis and investigation
- Emergency Department overcrowding
- Inadequate nursing staffing
- Lack of available SCOVID isolation beds
- Limited physical assessment spaces
- Delayed patient flow to wards
- Infection control precautions delaying assessment
- Waiting room nurse redeployment
Coroner's recommendations
- Staff the Emergency Department of University Hospital Geelong to at least the minimum levels recommended by ACEM G23
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