Coroner's Finding: Chadha, Hemant and Battagodage, Sachintha Nandula

Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Battagodage: acute haemothorax due to ruptured pseudoaneurysm of right subclavian artery

Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hospital despite three ED presentations within 4 days and concerning new symptoms (numbness, tingling). Ambulance officers treated him dismissively, undermining his confidence in the health system and contributing to his refusal to call for help when critically ill. Sachintha Battagodage (23) died of rupture of a pseudoaneurysm of the right subclavian artery after haemoptysis was underappreciated at RAH. On first presentation, no chest x-ray was performed despite haemoptysis in a young previously well patient. On re-presentation with moderate-to-frank haemoptysis, he was again discharged without admission despite abnormal imaging, partly due to language barriers and failure to review video evidence. Both deaths were preventable with appropriate senior review of repeat presentations, thorough assessment of concerning symptoms, and proper investigation.