Inquest into the Death of Petra ZELE

Contributing factors

• failure to take adequate medication history, specifically oral contraceptive pill use
• misdiagnosis of musculoskeletal chest pain without adequate investigation
• failure to order D-dimer or ECG despite chest pain presentation
• ECG performed but result not communicated to treating doctor
• failure to apply Wells or PERC criteria for PE risk stratification
• lack of clinical context (referral form and patient questionnaire) available to reporting cardiologist
• delay in communicating serious echocardiogram findings to patient
• failure to convey urgency to patient after abnormal echocardiogram
• inability to contact intended specialist on Friday afternoon
• Factor V Leiden mutation combined with drospirenone-containing oral contraceptive pill use

Coroner's recommendations

1. General practitioners should advise patients prescribed oral contraceptive pills that it is a medication that should be reported when asked to complete medical questionnaires, provide medical history, or when asked about medications. This recommendation forwarded to Western Australian office of Royal Australian College of General Practitioners.
2. Doctors reporting echocardiograms in patients with newly diagnosed serious conditions such as pulmonary hypertension should consider contacting the patient where possible and practical.
3. Medical referrals should be directed to doctors with relevant expertise rather than to named individuals, to avoid delays due to unavailability.
4. Echocardiography services should have protocols for technicians to advise cardiologists immediately of significantly abnormal findings, preferably before patient leaves laboratory, to allow cardiologist assessment and direction to appropriate facility.
5. All ECGs must be properly labelled; nursing staff should label any unlabelled ECG before giving to doctor for review, and doctors should not accept unlabelled ECGs.
6. Emergency Department staff should conduct detailed medication histories including specific questioning about oral contraceptive pill use for all female patients of reproductive age.
7. Wells criteria for PE assessment should be documented in medical notes.
8. Consideration should be given to second set of vital observations, chest X-ray, and specific questioning about exercise tolerance reduction in differential diagnosis of chest pain.
9. Better review processes at senior level for clinical incidents and sentinel events.
10. Reinforced education on pulmonary embolism diagnosis and investigation of breathlessness for all medical staff, with quarterly sessions for ED staff.
11. Echocardiography reporting should include access to referral forms and patient questionnaires to provide clinical context.
12. Time and date-stamped documentation of conversations between reporting specialist and referring doctor.