Finding into death of Patrick Paul

68y · Male·Ischaemic heart disease and coronary artery atherosclerosis

Patrick Paul, a 68-year-old man with significant cardiac history including prior myocardial infarction and coronary stents, died of ischaemic heart disease while in prison custody. He presented to hospital with symptoms suggestive of acute coronary syndrome (epigastric pain radiating to back, chest pain, dyspnoea, sweating) but was diagnosed as alcohol withdrawal by the assessing doctor. His troponin was negative and ECG unchanged, leading to discharge back to prison with aspirin. He died the following day. Key clinical lessons: (1) in patients with established ischaemic heart disease presenting with chest pain and constitutional symptoms, acute coronary syndrome must remain high on the differential diagnosis regardless of recent alcohol cessation; (2) negative troponin at presentation does not exclude evolving myocardial infarction, particularly in the early hours; (3) serial troponins and ECGs should be considered; (4) the attribution of all symptoms to alcohol withdrawal may result in anchoring bias, missing organic pathology.