Coroner's Finding: Howard, Noeline Dawn

76y · Female·pulmonary embolism due to carcinomatosis

A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carcinomatosis) with multiple pulmonary emboli. A CTPA was requested but could not be performed because she was unable to lie flat; no alternative investigation such as ECG was documented. Prophylactic anticoagulation was delayed until day 3. She deteriorated acutely on day 6 and died despite resuscitation. The coroner found there was a significant delay in reaching the correct diagnosis and initiating appropriate treatment. A respiratory specialist opined that earlier accurate diagnosis and treatment may have improved short-term outcome, though uncertainty remains about whether it would have changed the final result.