Hemsley, Joanne - non-inquest findings

55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infarct due to coronary atherosclerosis treated by recent stents placement/angioplasty with complications

A 55-year-old woman with extensive coronary artery disease presented for elective stent placement to her left anterior descending artery. During the procedure, a small diagonal branch vessel was occluded—a recognised complication affecting 1–5% of cases. The interventional cardiologist did not document this complication or provide clear clinical direction for post-procedure management. The patient was discharged the next morning without appropriate cardiac enzyme testing or extended observation despite having chest pain and ECG changes following the procedure. She died at home 16 hours later from cardiac rupture and tamponade. The coroner found the patient was discharged too soon; had she remained hospitalised, the rupture likely would have been detected clinically and may have been amenable to emergency surgical repair. Key failures included failure to document the procedural complication, absence of enzyme monitoring despite post-procedure symptoms, and inadequate handover of critical clinical information.