Coroner's Finding: Newett, Margaret Wynne

77y · Female·combined effects of ischaemic heart disease and calcific aortic valve sclerosis

Margaret Wynne Newett, 77, had moderate aortic stenosis diagnosed in 2011 but was never monitored with follow-up echocardiography as guidelines recommend. On 30 December 2013, she collapsed in a supermarket. At West Coast District Hospital, her ECG was abnormal but a cardiology registrar advised deferring troponin testing and arranging outpatient echocardiogram rather than urgent transfer to Royal Hobart Hospital's cardiac unit. She was discharged, collapsed again on 4 January, and was admitted to North West Regional Hospital with confirmed myocardial infarction and severe ischaemic changes. She developed atrial fibrillation, arrested and died. The coroner found her death possibly preventable if her serious condition and syncope presentation had prompted urgent referral and cardiac assessment. Key failures included: no follow-up echocardiography post-diagnosis, incomplete ECG interpretation, failure to test troponin acutely, and the registrar's non-escalation of a critical situation. Recommendations were formal telephone advice protocols and annual cardiology review for aortic stenosis patients.