Finding into death of Elizabeth Mary Gorman

35y · Female·Pulmonary thromboembolus and pulmonary infarction

A 35-year-old woman at 11 weeks gestation presented to Royal Women's Hospital Emergency Care on 3 September 2012 with chest and rib pain following severe vomiting. Dr M., a junior resident working alone overnight, assessed her as musculoskeletal pain and discharged her without ECG or imaging. She returned 17 hours later in near-cardiac collapse with massive bilateral pulmonary emboli and died despite thrombectomy. The coroner found Dr M.'s assessment insufficiently thorough—PE should have been more actively excluded through basic investigations (ECG, chest X-ray). Systemic failures included inadequate emergency medicine supervision, lack of guidelines requiring ECG for chest pain, and barriers to accessing senior advice. Ambulance paramedics also erred by transporting her to RWH rather than RMH, contrary to time-critical protocols.