Coxell 2011 06 14 12 32 04 475

61y · Male·cardiac tamponade caused by aortic dissection due to hypertension

Harry Coxell, a 61-year-old man with hypertension, presented to Blacktown Hospital with severe sudden-onset chest pain on 31 October 2006. The Emergency Department doctor, Dr H., assessed him as intermediate risk for ischaemic heart disease and admitted him to the cardiac care unit. On 1 November, junior doctors Dr W. and Dr C. identified recurrent chest pain and a new cardiac murmur but failed to recognize these as contraindications to exercise stress testing or to escalate to the on-call cardiologist. Dr W. performed the stress test while the patient had active chest pain. The patient collapsed during the test and died. Post-mortem examination revealed he had suffered an aortic dissection since his initial presentation. The coroner found the death was preventable: adequate consideration of aortic dissection in the ED, recognition of recurrent pain and the murmur as contraindications to the stress test, and escalation to senior medical staff would likely have prevented the fatal outcome. Multiple systemic failures in protocols, documentation, communication, and training were identified.