McKenzie, Jillian Peta

47y · Female·Cardiac arrhythmia due to severe coronary artery atherosclerosis

A 47-year-old woman presented to a level one rural hospital with chest pain. The doctor diagnosed muscular pain (99% certain) and discharged her without troponin testing or admission, despite chest pain being the presenting complaint. She died of cardiac arrhythmia secondary to coronary atherosclerosis that night. The coroner found the doctor failed to follow National Heart Foundation Guidelines requiring intermediate risk classification, admission, and serial cardiac testing until acute coronary syndrome could be excluded. No firm advice was given to attend the larger hospital. While the patient might not have survived even if admitted, she would have had a better chance. The case highlights risks of deploying junior doctors unsupervised to rural hospitals without clear referral protocols. Inadequate risk stratification and failure to follow evidence-based guidelines for chest pain assessment directly contributed to the preventable missed opportunity for appropriate investigation and management.