Coroner's Finding: Roberts, Leigh Ronald

56y · Male·coronary atherosclerosis

Leigh Ronald Roberts, 56-year-old male, died from coronary atherosclerosis with severe stenosis affecting all three main coronary arteries. He presented to his GP on 17 and 21 February 2020 with respiratory symptoms (cough, shortness of breath, fever) attributed to a chest infection. Critical clinical lesson: Roberts had multiple uncontrolled cardiovascular risk factors (hypertension, hyperlipidaemia, overweight, significant family history of early coronary death) that were inadequately managed. His antihypertensive and cholesterol-lowering medications had been discontinued without documented reason. On his final consultation, he reported chest symptoms (chest went "backwards") and dyspnoea on exertion, yet no chest pain was documented and no ECG or chest X-ray was arranged. The coroner found that proactive questioning about chest pain, given his risk profile and deteriorating presentation, would likely have prompted hospital referral and investigation, potentially preventing death.