Coroner's Finding: BEGG Peter Albert

62y · Male·Ischaemic heart disease due to coronary atherosclerosis

Peter Albert Begg, a 62-year-old prisoner, died of ischaemic heart disease due to severe coronary atherosclerosis with contributing dothiepin toxicity. He collapsed while pushing a food trolley and did not respond to resuscitation. He had reported chest pain and shortness of breath two months prior, for which the prison doctor prescribed nitrolingual spray. An expert reviewer noted that management of his cardiac symptoms and unexplained blackouts over four years was suboptimal. The blackouts could have represented cardiac arrhythmias warranting further investigation including stress testing and holter monitoring. While dothiepin dosing was appropriate and unlikely the primary cause, better diagnostic investigation of his cardiac symptoms might have identified severe coronary disease earlier and potentially prevented his fatal collapse.