Coroner's Finding: DALLING Brian Terrance and SALOTTI Jack William and GRZYWACZ Richard John and SOBEY Brian Leslie

Male·acute myocardial infarction due to coronary artery disease (all four); specific causes: acute myocardial infarct due to coronary artery thrombosis secondary to coronary artery atherosclerosis (Dalling); ischaemic heart disease due to coronary atherosclerosis (Salotti, Grzywacz, Sobey)

Four rural South Australian men (aged 42-76 years) died from acute coronary syndrome in 2004-2006. All presented to country medical practitioners with symptoms suggestive of acute coronary syndrome but were not identified as such. Key failures included: failure to obtain or act on previous abnormal ECGs indicating prior myocardial infarction; inadequate risk factor assessment (particularly diabetes, smoking, hypertension, family history); failure to follow diagnostic protocols requiring immediate ECG and troponin testing; misinterpretation of ECG changes or failure to seek specialist ECG interpretation despite available iCCNet services; discharge based on single negative troponin tests taken before meaningful positivity expected; and failure to appreciate that negative initial troponin/ECG does not exclude acute coronary syndrome. All four men should have been transferred to tertiary Adelaide hospitals for urgent coronary angiography. Clinical lessons: take chest pain seriously even with alternative explanations present; always consider acute coronary syndrome diagnosis first; obtain complete risk factor history; follow standardized protocols for chest pain; compare serial ECGs for dynamic changes; understand troponin timing limitations; seek specialist ECG interpretation when uncertain; never reassure patients based solely on negative early tests.