Finding into death of James Thomas Reilly

86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall

James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed transient ischemic attack. Clinical fixation on stroke diagnosis led to failure to adequately assess his back pain. Rib fractures went undiagnosed despite being the critical injury. The chest x-ray had low sensitivity for fractures. Additionally, an ED clinician erroneously prescribed 100mg therapeutic enoxaparin for the wrong patient due to EMR design flaws and lack of verification; nursing staff did not question it. Dual antiplatelet therapy for TIA combined with anticoagulation likely contributed to haemothorax progression. When he deteriorated the next morning with hypoglycaemia, hypoxia and hypotension, a tension haemothorax was identified. Intercostal catheter insertion was attempted but unsuccessful. The coroner recommended improved trauma assessment protocols and EMR interface improvements.