Coroner's Finding: LAZOPOULOS Christopher

34y · Male·multi-organ failure with right-sided tension pneumothorax

A 34-year-old man with a ruptured spleen and fractured ribs presented to the Emergency Department on multiple occasions with abdominal and chest pain. He was discharged on 28 February, 5 March and 6 March without admission despite clear indicators of serious pathology: severe pain (15/10), tachycardia (138-121 bpm), and a chest x-ray showing left base consolidation and pleural effusion concerning for pneumonia. The x-ray report was unavailable to treating doctors on 5 March and unreviewed on 6 March. Clinical correlation of abnormal imaging was never performed. Early diagnosis and antibiotic treatment on 5 March might have prevented fatal progression to multi-organ failure with tension pneumothorax. Key learning: when re-presenting patients have severe symptoms with radiological abnormalities suggesting infection, senior clinician review and timely integration of all diagnostic information (imaging plus clinical findings) are essential to avoid missed diagnosis of evolving sepsis.