Coronial
WAhospital

Inquest into the Death of Fabian Alec COFFIN

Deceased

Fabian Alec COFFIN

Demographics

51y, male

Coroner

Coroner Jenkin

Date of death

2024-02-05

Finding date

2025-02-21

Cause of death

complications of myocardial infarction in association with ischaemic heart disease

AI-generated summary

A 51-year-old prisoner died from complications of myocardial infarction with ischaemic heart disease. He had multiple cardiovascular risk factors including type-2 diabetes, hypertension, high cholesterol, chronic kidney disease, obesity, and smoking history. On 26 January 2024, he presented with jaw pain extending to chest and chest tightness; an ECG was normal and he was not admitted despite atypical presentation in a diabetic patient. On 1 February, he presented with worsening chest pain and low oxygen saturation (89%), was appropriately sent to hospital, and underwent cardiac catheterisation with stent placement. He suffered cardiac arrests on 4 and 5 February and died despite resuscitation. The coroner found supervision and medical care in prison were appropriate and of good standard. Clinical lessons: diabetic patients may present atypically with cardiac pain; jaw pain with chest pain warrants higher suspicion for acute coronary syndrome; the initial presentation on 26 January may have warranted hospital admission for observation and cardiac biomarkers despite normal ECG.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

cardiologyemergency medicineintensive carecorrectional healthnephrology

Error types

diagnostic

Drugs involved

insulinantihypertensive medicationsstatinantacid medication

Clinical conditions

acute myocardial infarctionischaemic heart diseasetype 2 diabetes mellitushypertensiondyslipidaemiachronic kidney diseasediabetic nephropathyobesitydiabetic retinopathygastro-oesophageal reflux diseasecardiac arrest

Procedures

electrocardiogramcardiac catheterisationcoronary angiographystent insertioncardiopulmonary resuscitationdefibrillation

Contributing factors

  • type 2 diabetes mellitus with poor control from late 2020
  • hypertension
  • dyslipidaemia despite maximal therapy
  • chronic kidney disease secondary to diabetic nephropathy
  • obesity with BMI in high 30s
  • smoking history
  • atypical presentation of acute coronary syndrome
  • possible delayed recognition of cardiac symptoms on 26 January 2024
Full text

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