Conlan, Kathleen Anne

70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exacerbated by coronary heart disease

Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigastric pain and was appropriately admitted for investigation. Initial blood tests and CT scan showed no evidence of gastrointestinal bleeding. Her symptoms improved and she was discharged, but re-admitted hours later when blood tests showed elevated white cell count. She deteriorated suddenly with evidence of upper GI bleeding and collapsed. The coroner found treatment prior to discharge was appropriate based on available evidence. Key learning: gastric haemorrhage onset was acute and unpredictable. The blood gas abnormalities (pO2 49, O2 sat 86%) on re-admission should have prompted repeat testing and oxygen therapy as precaution, though this would likely not have changed the outcome. No diagnosis was made before discharge, which was reasonable given symptom resolution, but discharge documentation should have been provided to the general practitioner.