Coroner's Finding: ZERK Ike Jordan

14y · Male·ventricular arrhythmia on a background of congenital aortic valve disease

A 14-year-old boy with congenital aortic stenosis collapsed and died from ventricular arrhythmia during football training in March 2015. He had undergone aortic valve repair in 2006 and was under long-term cardiology follow-up. At his September 2014 appointment, echocardiography showed a mean pressure gradient of 57.7 mmHg (above the 50 mmHg surgical intervention threshold), but Dr A. failed to: (1) advise cessation of strenuous physical activity pending surgery, and (2) ensure the September 2014 echocardiogram report reached the Melbourne surgical team—a letter sent in December 2013 also never arrived. Had the report reached Melbourne, surgery would have been arranged within 3-6 months and the family would have restricted his activity. The coroner found the death preventable due to these communication failures and lack of appropriate activity restriction advice.