Finding into death of Sally Elizabeth Hopwood

57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenital heart disease

Sally Hopwood, 57, with Turner syndrome, coarctation of the aorta, and bicuspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She was admitted to CCU under cardiologist Dr G.. Over 8 days, her presentation was reinterpreted as abdominal pathology (suspected choledocholithiasis, later pneumonia), despite imaging showing bilateral effusions. No CT chest was ordered despite her high-risk cardiac history and the X-ray findings. She died from ruptured thoracic aortic dissection with haemothorax. Key failures: Dr G. did not review the X-ray report; inadequate handover between Dr C. and Dr G. regarding the X-ray significance; misattribution of findings to abdominal pathology; missed opportunity when CT cholangiogram revealed lung effusions. Early CT chest imaging would likely have allowed percutaneous stent treatment.