Finding into death of Marlene Kenny

64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral artery stroke and ST elevation AMI

Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation. She re-presented next day with neurological symptoms (arm weakness, slurred speech) suspicious for TIA. The hospital failed to recognise she had a paradoxical stroke caused by a patent foramen ovale allowing a blood clot to cross from right to left circulation. Transfer to tertiary care was delayed over 9 hours due to poor communication between hospital and ambulance services about clinical urgency, ineffective bed coordination, and adverse weather. She deteriorated, suffered myocardial infarction, and died from bilateral pulmonary embolism complicated by stroke. Key failures: initial hypoxia not investigated; complexity not recognised on readmission; escalation inadequately documented; transfer delayed by communication breakdown and transport resource constraints. Earlier recognition of complexity and expedited transfer would have significantly enhanced her prospects.