Coroner's Finding: CARTER Kenneth Morton

76y · Male·ruptured abdominal aortic aneurysm

Kenneth Carter, 76, died from a ruptured abdominal aortic aneurysm (AAA) on 8 June 2005. He had presented to Flinders Medical Centre Emergency Department on 1 June 2005 with back pain, hypotension (90/65 mmHg), and two episodes of syncope at his physiotherapist. Despite a documented prior AAA repair in 1992, the Emergency Department and subsequently Dr A. at Flinders Private Hospital focused on suspected infection (pneumonia/sepsis) based on elevated white cell count, C-reactive protein, and toxic granulation. No abdominal CT scan was performed. The coroner found it more probable than not that Mr Carter was experiencing a leaking AAA on 1 June 2005, with characteristic symptoms: back/abdominal pain, hypotension, and syncope. While toxic granulation supported an infective diagnosis, the coroner found no error in Dr A.'s management given the strong clinical picture of infection presented by the Emergency Department. However, the Emergency Department initially should have considered AAA in its differential diagnosis given the constellation of symptoms and prior AAA history. A CT scan would likely have been diagnostic and might have allowed intervention, though prognosis would have been poor given Mr Carter's comorbidities.