Coroner's Finding: Hoskinson, Neville Robert

55y · Male·cardiac tamponade resulting from proximal aortic dissection due to hypertension

A 55-year-old man presenting with acute severe chest pain, headache and jaw pain to a regional hospital was evaluated for aortic dissection. A CT angiogram was performed but the radiologist's verbal report contained ambiguities and omissions compared to the written report, which mentioned possible mediastinal haemorrhage. Clinicians documented 'no dissection' despite the written report not definitively excluding it. A transthoracic echocardiogram ordered by cardiology was cancelled the next day due to an administrative error, delaying diagnosis by 24 hours. When imaging was resumed, a transoesophageal echocardiogram confirmed dissection but the aorta further dissected during the procedure, causing cardiac tamponade and death. Had diagnosis occurred one day earlier, the patient had a 60% survival prospect.