Inquest into the Death of Petra ZELE

28y · Female·hypoxic brain injury following cardiac arrest in association with pulmonary hypertension (acute pulmonary embolism on chronic thromboembolic pulmonary disease)

Petra Zele, a 28-year-old woman, died from hypoxic brain injury following cardiac arrest due to acute pulmonary embolism superimposed on chronic thromboembolic pulmonary hypertension. She presented to Fremantle Hospital ED on 9 May 2010 with chest pain but was diagnosed with musculoskeletal pain and discharged. Clinical lessons include: (1) Dr H. failed to adequately assess PE risk by not specifically asking about oral contraceptive use (a key risk factor), despite the patient being on Yasmin; (2) an ECG was performed but not properly communicated to the doctor; (3) no D-dimer or further investigations ordered; (4) two weeks later, Dr B. identified severe pulmonary hypertension on echocardiogram but lacked clinical context, and neither she nor Dr U. conveyed appropriate urgency to the patient. The death was likely preventable had PE been diagnosed on 9 May and appropriate therapies initiated. Key preventive measures: detailed medication history including contraceptive pill, specific PE risk assessment using Wells/PERC criteria, appropriate investigation of chest pain and pleuritic symptoms, and timely communication of serious findings.