'Missed diagnosis' in Tas woman's death

·2-min read

An elderly woman may not have died had results of a heart test at a hospital in northern Tasmania been properly interpreted, a coroner has ruled.

Beryl Jean Ridgeon, 83, was taken by her daughter to Mersey Community Hospital in December 2019 after she was feeling unwell and had trouble eating.

She was diagnosed with gastroenteritis, given anti-nausea medication and sent home.

Mrs Ridgeon was found dead in bed by her daughter the following morning.

In findings published this week, coroner Simon Cooper found staff at the hospital appear to have "completely missed" that she had suffered a myocardial infarction, commonly known as a heart attack.

Mrs Ridgeon had undergone an ECG test at the hospital.

"That ECG showed clearly that Mrs Ridgeon had suffered a myocardial infarction," Mr Cooper wrote.

Mrs Ridgeon died from haemopericardium, with underlying conditions being a ruptured acute myocardial infarction and coronary atherosclerosis.

Mr Cooper wrote it is imperative staff at the hospital receive appropriate training in how to interpret ECG results.

"If the ECG had been properly interpreted, Mrs Ridgeon may not have died," he added.

An analysis conducted by the Tasmanian Health Service (THS) after Mrs Ridgeon's death found the diagnosis of gastroenteritis was "anchored" throughout.

There was no exploration for alternative or differential diagnosis, it read, with the ECG not formally ordered as part of the medical work-up, rather as a routine process.

Mrs Ridgeon, who was born in England, had worked in northwest Tasmania as a nurse, including a stint at the then-named Mersey General Hospital in the 1970s.

The THS says a number of measures have since been put in place to ensure practices are the best they can be.

"All ECG machines at the Mersey Community Hospital have had automatic interpretation enabled," a spokesman said.

"Nurses are required to present ECGs to the FACEM or senior clinician on shift; and emergency department staff are required to save ECGs on monitors prior to printing so that records are available."

The emergency department's clinical lead has appointed a member of the medical team as an ECG mentor who conducts regular case study sessions with staff, he said.

The hospital has extended condolences to Mrs Ridgeon's family.