Coroner's Finding: Mitchell, Gordon Arthur David

54y · Male·acute myocardial infarction

Gordon Arthur David Mitchell, 54 years old, died of acute myocardial infarction five days after successful stenting for an initial MI. He was discharged on 10 July 2019 despite presenting with chest pain, dyspnea, and cold sweats on discharge day, with documented ventricular tachycardia episodes. The coroner found his first admission (5-8 July) was appropriately managed, but the second presentation (8-10 July) was poorly managed. Critical failures included: failure to recognize the serious prognostic implications of ventricular tachycardia occurring three days post-infarction; inadequate monitoring duration before discharge; and failure to consider implantable defibrillator insertion. The coroner concluded he should have been monitored longer and defibrillator insertion should have been considered. Access to specialist cardiology advice after-hours in rural settings was identified as a systemic issue.