The Northern Territory coroner has found the death of a 35-year-old woman from an "exceedingly uncommon" heart condition in a Darwin hospital to have been "unavoidable".
Warning: This story contains the name of an Indigenous person who has died, used with the permission of her family.
Janelle – as her family requested she be called – died of a rare Type A aortic dissection seven hours after she was rushed to Royal Darwin Hospital (RDH) from the remote community of Bulman, around 300 kilometres north-east of Katherine, in July 2021.
She had been suffering mental health issues and was sectioned in the hospital's mental health ward when she began complaining of chest pain and was found to have a high heart rate.
Under territory law, Janelle's death was a "death in care" and required a mandatory coronial inquest.
Coroner Elisabeth Armitage found Janelle's death was "unavoidable" and made no recommendations, writing her care by medical staff was "appropriate."
"It is tragic and regrettable that a 35-year-old woman who had none of the risk factors usually seen in a person suffering from an aortic dissection, passed away unexpectedly from such a rare condition," Judge Armitage wrote.
Specific test not completed at RDH
Throughout the inquest in February the coroner heard from expert medical witness Professor John Raftos, who said a CT thoracic angiogram should have been performed at the same time as the CT pulmonary angiogram that Janelle received around four hours before she died.
"If a CT thoracic angiogram had been performed at the same time, as should probably have been the case, it would, more likely than not, have shown diagnostic evidence of thoracic aortic dissection," Professor Raftos said.
However, he also said Janelle would have needed cardiothoracic surgical treatment, which is unavailable at RDH, within the space of a few hours if she was to have a chance of surviving.
"[Janelle] would not have survived, even if her thoracic aortic dissection had been diagnosed on the evening of 3 July 2021," Professor Raftos said.
The director of the emergency and trauma centre of RDH, Associate Professor Didier Palmer, disagreed with parts of Professor Raftos's assessment of the situation, telling the coroner the process that diagnosing doctors followed was appropriate.
"Complex condition diagnosis is akin to peeling an onion one layer at a time. You sequentially exclude the likely diagnoses ... and then progress to exclude less likely conditions," he said.
"I would not consider this a missed diagnosis. The diagnostic process was proceeding appropriately but could not outpace the disease process."
Dr Palmer said even if the aortic dissection had been detected on the night Janelle died, she would have still been waiting for transport to Adelaide at the time she ultimately suffered a cardiac arrest.
Over-testing would 'grind system to a halt'
In her findings, coroner Elisabeth Armitage wrote that the additional CT scan recommended by Professor Raftos was not conducted partly because of how rare the suspected disease was.
"If such a practice were applied to the management and treatment of every patient in [the emergency department] there would be simultaneous testing for scores of conditions which would be unlikely to yield results and such over-testing would grind the system to a halt," Judge Armitage wrote.
"The absence of a cardiothoracic surgery service at RDH meant that nothing could be done to save her in Darwin, and she would have passed away before any transfer to Adelaide was achievable."
The coroner expressed her condolences to Janelle's family and said she was satisfied her death was unavoidable "despite the best efforts" of all medical staff involved.
