Inquest into the death of Leonard Bartholomeusz

73y · Male·Consequences of myocardial infarction with coronary artery atherosclerotic disease being an antecedent cause (myocardial rupture)

Leonard Bartholomeusz, aged 73, died of myocardial rupture on 6 May 2013, six days after hip fracture surgery. He suffered a fall on 30 April 2013 following which ECG testing revealed cardiac abnormality. A first ECG at Sydney Hospital showed minor non-specific ST changes that did not meet diagnostic criteria for STEMI; expert opinion supported that no further action was warranted given the clinical context. A second ECG at Prince of Wales Hospital performed later that night showed definite STEMI, but was never brought to treating clinicians' attention due to systemic failures in ECG management. The coroner found the second ECG was catastrophically overlooked and that appropriate escalation to cardiology with admission to coronary care unit would have been indicated. However, it remains uncertain whether earlier intervention would have altered the fatal outcome, as evidence suggested his left anterior descending artery spontaneously re-perfused and the timing of rupture at day 6 post-MI was not necessarily preventable with early treatment. The delirium investigation was deemed appropriate given the clinical context.