Finding into death of Zoran Georgievski

40y · Male·haemopericardium complicating ascending thoracic aortic dissection

A 40-year-old man presented to the Northern Hospital ED with acute chest pain radiating to his throat, diaphoresis, and left hand tingling. Initial assessment by a junior doctor appropriately excluded cardiac ischaemia and he was discharged on day 2 with a diagnosis of reflux. He died two days later from rupture of an ascending thoracic aortic dissection with haemopericardium. Post-mortem imaging revealed widened mediastinum on the initial chest x-ray. The coroner found preventable failures: the x-ray was likely never properly reviewed by ED clinicians before discharge; the consultant radiologist (Dr T.) failed to identify the marked mediastinal widening and did not alert the ED; and escalation to senior imaging review on a full-resolution screen did not occur. However, the presentation was atypical for dissection, clinical suspicion was justifiably low, and junior doctors could not be expected to diagnose this subtle radiological finding. The primary failure was the radiologist's perceptual error and lack of communication.