Coroner's Finding: Donohue, Tracey Lee

44y · Female·Ischemic heart disease due to complete blockage of left anterior descending coronary artery

A 44-year-old woman presented with acute chest pain and troponin elevation. Coronary angiography revealed only a 30% non-obstructive lesion in the left anterior descending artery. She was discharged on aspirin alone without dual antiplatelet therapy or a statin, despite a cardiologist's letter recommending dual antiplatelet therapy. The treating cardiologist attributed this decision to concerns about gastric dyspepsia and concurrent opioid use. Two months later, she died from a complete thrombotic occlusion of the same artery. The coroner found the treatment decisions were not unreasonable given the diagnostic complexity from her chronic pain history, but noted that retrospectively, dual antiplatelet therapy and statin therapy would have improved survival chances. Key lessons: consider secondary prevention after acute coronary events even with minor angiographic findings, ensure medication recommendations from specialists are clearly communicated and actioned, and document clinical reasoning for deviating from specialist recommendations.