Finding into death of Jason Joseph Mirko Ljepojevic

30y · Male·Haemopericardium due to dissecting aortic aneurysm secondary to bicuspid aortic valve

A 30-year-old man in prison presented with severe central chest pain radiating to neck and back after gym exercise. A GP conducted physical examination, ECG, and diagnosed musculoskeletal pain. Pain improved within hours. He died the next day from dissecting aortic aneurysm secondary to bicuspid aortic valve. The coroner found the GP's assessment reasonable and appropriate given the clinical presentation and information available. Expert evidence confirmed aortic dissection is extraordinarily rare in this age group, impossible to diagnose as a GP, and even if referred to ED, likely would not have been detected or changed survival outcome (mortality rate 50% within 24 hours of diagnosis). No adverse findings made against the treating physician.