Coroner's Finding: CAMERON Louise Cherise

32y · Female·ischaemic heart disease complicated by upper gastrointestinal haemorrhage

A 32-year-old woman with schizophrenia presented to the emergency department with chest pain radiating to both arms, profuse sweating, and vomiting black material for several days. She also reported black stools. The first-year medical officer and senior doctor diagnosed oesophagitis, ordered morphine, and discharged her after ~2 hours with a single troponin test and ECG. She died the next day from acute coronary thrombosis complicated by upper gastrointestinal haemorrhage. Critical omissions included: failure to perform a rectal examination despite clear signs of gastrointestinal bleeding (black chunks in stool/vomit); failure to obtain serial troponin tests (only one test at admission); and inadequate interpretation of the abnormal ECG showing Q waves suggesting prior cardiac damage. Had either condition been detected—particularly the GI bleed via rectal examination—hospital admission would have occurred, potentially preventing death. Supervision and protocols for chest pain assessment were inadequate.