Coroner's Finding: TESTER Ernest Robert

91y · Male·Severe heart failure secondary to ischaemic cardiomyopathy

Ernest Robert Tester, a 91-year-old man with ischaemic cardiomyopathy and severe heart failure, died in an aged care facility. He experienced chest tightness and difficulty breathing at 2am, treated appropriately by nursing staff with oxygen, GTN spray, oxazepam, Ventolin, and morphine according to his palliative care plan. His symptoms improved and staff handed over to the day shift with instructions to call the doctor if deterioration occurred. He was found deceased at 8:30am. The coroner found death resulted from natural causes consistent with his medical history and existing palliative care plan. No clinical errors or preventable factors were identified. The case illustrates appropriate end-of-life care management in aged care and the importance of clear handover communication regarding escalation thresholds.