Coroner's Finding: Gordon, Mark Alexander

51y · Male·Pericardial tamponade complicating Type I aortic dissection in the setting of long-standing hypertensive cardiovascular disease

Mark Gordon, 51, presented to Royal Hobart Hospital Emergency Department on 20 March 2015 with sudden onset chest pain. Initial assessment suspected acute coronary syndrome with elevated troponin. Over 36 hours he experienced multiple warning signs: unwitnessed syncope, light-headedness, pain radiating to his back, and pleuritic chest pain. Despite these classic signs of aortic dissection, no such diagnosis was considered by the medical team, including a consultant physician. No CT imaging was obtained. The patient arrested on 22 March and died. Autopsy revealed Type I aortic dissection with pericardial tamponade. The coroner found the diagnosis should have been considered, especially after back pain and syncope developed, and criticized the medical staff for failing to recognize this life-threatening condition. Early imaging and surgery offered approximately 65% chance of survival.