Coroner's Finding: Patrick, Robert David

65y · Male·ruptured abdominal aortic aneurysm

A 65-year-old man with recently diagnosed small cell lung cancer presented to a rural hospital with acute back pain. He had a known abdominal aortic aneurysm (73mm) identified on staging scans. The attending nurse documented elevated blood pressure (195/110) and the aneurysm history, but this critical information was not communicated to the on-call doctor. The doctor diagnosed musculoskeletal back strain from lifting equipment and prescribed ketorolac. The patient was discharged; he died at home the following morning from ruptured aortic aneurysm. The coroner found that while correct diagnosis at the hospital would have been reasonable if the doctor had reviewed the full clinical picture including blood pressure and aneurysm history, the logistical challenges of transferring a patient from a remote location to the only facility capable of emergency aortic surgery made survival unlikely even with correct diagnosis.