5y · Female·myocarditis
…ECG by both the registrar and consultant paediatrician; lack of allocated responsibility for following up troponin test results; failure of ICU to properly assess the critically ill child despite consultation; inadequate…
68y · Female·Acute myocardial infarction and coronary artery atherosclerosis
…rosis. Clinicians failed to consider myocardial infarction despite atypical presentation and did not test troponin initially. Key lessons: maintain high suspicion for acute coronary syndrome in females presenting atypica…
37y · Male·Haemopericardium secondary to aortic dissection
…ain, diaphoresis and nausea. Dr G., the sole ED physician, conducted initial assessment including ECG and troponin testing, both normal. He diagnosed gastritis and admitted for observation. Costello collapsed in shower t…
64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…
…ayed recognition of severe metabolic derangement; incomplete vital sign documentation; failure to perform troponin testing; and delayed physician attendance. RN Magazini did not call an ambulance when indicated by guidel…
24y · Male·Coronary artery thrombosis secondary to coronary atherosclerosis
A 24-year-old Aboriginal man collapsed during football in extreme heat and presented to a rural clinic with dizziness, chest pain, shortness of breath and sweating. The nurse diagnosed dehydration and administered IV flu…
72y · Male·Subarachnoid haemorrhage in a man with coronary arteriosclerosis
…nd aspirin. Multiple doctors reviewed him and found his presentation consistent with cardiac disease; his troponin was negative and ECG showed no acute transmural changes. Around midnight on 22–23 October 2000, he suffer…
33y · Male·Decompensated congestive cardiac failure complicating acute myocardial infarctio…
…yndrome despite ECG changes on second visit. ED correctly diagnosed acute coronary syndrome with elevated troponin. However, cardiogenic shock developed during admission, requiring intensive haemodynamic support. Medical…
35y · Female·aortic dissection with associated acute aortitis
…t transport was timely and the receiving ED team initiated appropriate chest pain investigation including troponin, ECG, CTPA and D-dimer testing. However, she suffered a rare Type A aortic dissection with acute aortitis…
68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…
…t pain with borderline ECG showing changes from previous baseline, without cardiac risk stratification or Troponin testing; and placement alone in his cell despite HRAT status mandating double occupancy. The coroner foun…
81y · Female·Cardiac tamponade secondary to dissection of ascending aorta
…n radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrome via troponin and ECG, she was discharged with undiagnosed chest pain after a 'chest pain pathway' without further inve…
77y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis of the left leg
…h thrombophilia presenting with dyspnoea and chest pain; anticoagulation status should be verified by INR testing rather than accepting patient report; ECG is mandatory in chest pain presentations; risk stratification t…
55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infar…
…post-procedure management. The patient was discharged the next morning without appropriate cardiac enzyme testing or extended observation despite having chest pain and ECG changes following the procedure. She died at ho…
65y · Male·Spontaneous lethal arrhythmia on a background of cardiomegaly, myocardial fibros…
… cardiomegaly) and a history of brain injury causing unpredictable behaviour. During detention for breath testing, he became agitated, struggled with police, and a lateral vascular neck restraint was briefly applied. He…
58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis
…e Wells score was applied. If it was applied (with a score of zero), clinical guidelines required D-dimer testing; this test would likely have been positive and led to further imaging, potentially identifying the PE bef…
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