Coroner's Finding: Ridgeon Beryl Jean

83y · Female·haemopericardium due to ruptured acute myocardial infarction with underlying coronary atherosclerosis

An 83-year-old woman presented to Mersey Community Hospital with vomiting and suspected gastroenteritis. An ECG was performed as a routine process and clearly demonstrated acute ST-elevation myocardial infarction (STEMI), but this critical finding was missed by clinical staff. She was discharged with anti-nausea medication. She died at home the following day from haemopericardium secondary to rupture of acute myocardial infarction. The coroner found that diagnostic anchoring to gastroenteritis prevented consideration of acute coronary syndrome, and that the ECG was not formally reviewed by senior clinicians. Proper ECG interpretation and consideration of differential diagnoses could have prevented this death.