Inquest into the Death of Fabian Alec COFFIN

51y · Male·complications of myocardial infarction in association with ischaemic heart disease

A 51-year-old prisoner died from complications of myocardial infarction with ischaemic heart disease. He had multiple cardiovascular risk factors including type-2 diabetes, hypertension, high cholesterol, chronic kidney disease, obesity, and smoking history. On 26 January 2024, he presented with jaw pain extending to chest and chest tightness; an ECG was normal and he was not admitted despite atypical presentation in a diabetic patient. On 1 February, he presented with worsening chest pain and low oxygen saturation (89%), was appropriately sent to hospital, and underwent cardiac catheterisation with stent placement. He suffered cardiac arrests on 4 and 5 February and died despite resuscitation. The coroner found supervision and medical care in prison were appropriate and of good standard. Clinical lessons: diabetic patients may present atypically with cardiac pain; jaw pain with chest pain warrants higher suspicion for acute coronary syndrome; the initial presentation on 26 January may have warranted hospital admission for observation and cardiac biomarkers despite normal ECG.