Coroner's Finding: Dent, Freda Lillian Florence

85y · Female·ischaemic heart disease due to stenosis of coronary bypass grafts

An 85-year-old woman with significant cardiac history (prior coronary artery bypass graft) presented with gastrointestinal symptoms. Her GP ceased rosuvastatin without direct communication to nursing staff. Care staff identified symptoms 5 hours later but failed to implement appropriate monitoring of vital signs and fluid balance. Communication with ambulance was poor and lacked urgency; critical delay occurred in the second call timing. Autopsy revealed blocked coronary bypass graft causing acute myocardial infarction. While preventability is uncertain given her severe cardiac disease, key failings included: absence of nursing staff at GP consultation, no documented action plan for close observation, delayed recognition of symptoms, poor fluid monitoring, and inadequate ambulance communication. Earlier vital sign assessment and clearer escalation protocols could potentially have improved outcomes.