Coroner's Finding: Rogers, Maureen Ann

71y · Female·cardiac tamponade due to ascending aortic dissection

A 71-year-old woman presented to the ED with sudden-onset epigastric pain requiring morphine. Despite clinical features concerning for acute aortic dissection (severe stabbing chest pain radiating to back, relieved by leaning forward, systolic ejection murmur, ECG changes), she was diagnosed with gastritis and discharged. The critical error was the radiologist's failure to recognise displacement of mural calcification on non-contrast CT indicating ascending aortic dissection—a finding acknowledged as 'obvious' by independent reviewers. The radiologist should have also warned that non-contrast imaging was inadequate to exclude dissection. Mrs Rogers died from cardiac tamponade that night. Immediate surgery (Bentall's procedure) offered 50-60% survival despite significant risks. This death was preventable through accurate radiological reporting and appropriate clinical escalation based on the clinical presentation.