Finding into death of Errol Leslie Solly

67y · Male·Ischaemic heart disease; coronary artery atherosclerosis (stented)

A 67-year-old man with extensive cardiac history presented to the ED with recurrent ischaemic-sounding chest pain. Despite multiple episodes of chest pain during admission, initial ECGs and troponins were normal. Following a telephone consultation with cardiology, he was discharged with a plan for outpatient investigations. He suffered a fatal inferior STEMI later that evening. The coroner found that further serial troponin testing should have been performed per the Assessment Protocol for patients with recurrent ischaemic chest pain, representing a missed opportunity to alter his clinical course. The case highlights the importance of adhering to risk stratification guidelines, particularly in settings without on-site cardiology specialists, and proper escalation procedures.