Finding into death of John Crabtree

69y · Male·Myocardial infarction secondary to coronary artery atherosclerosis in the setting of infective exacerbation of chronic obstructive pulmonary disease

Mr Crabtree, a 69-year-old man with intellectual disability, COPD, emphysema and heavy smoking history, presented to the ED with respiratory distress on 26 May 2016. He was diagnosed with infective exacerbation of COPD and treated for septic shock. However, autopsy revealed acute myocardial infarction secondary to critical coronary artery atherosclerosis. A planned ECG was not performed due to patient restlessness. The coroner found no clinical fault with ED or GP management based on information available at the time, but noted that an early ECG might have identified MI and potentially altered outcome if the patient was stable for catheterisation. A significant delay (58 minutes) in calling an ambulance from the group home was identified as a contributing factor that delayed medical attention, though survival remained unlikely given extensive coronary disease.