Dying after performing an exercise stress test – an avoidable death in a Sydney hospital

24 June 2011

Anna Walsh, Principal

A recent coronial inquest held in Sydney found that a lack of education of junior doctors about hospital protocols, as well as communication breakdowns between junior and senior hospital staff, led to the death of 61-year-old former policeman Harry Coxell.

Treatment at hospital

Mr Coxell died after attending Blacktown Hospital with chest pains in November 2006. He was taken by ambulance to the hospital where he was treated in the emergency department by a doctor who assessed him as being at an intermediate risk of suffering from ischaemic heart disease. Mr Coxell was subjected to various investigations and tests which were all reported as being normal. Unfortunately, doctors looking after Mr Coxell did not consider other cardiac conditions such as aortic dissection before deciding that he could be transferred to the cardiac ward for ongoing management.

On the ward, Mr Coxell was managed by a junior registrar who failed to follow hospital protocols for the management of patients with an acute coronary episode. This registrar also failed to recognise that the ongoing chest pains Mr Coxell was experiencing required a more senior doctor to review him. Mr Coxell was asked to participate in an exercise stress test, an investigation that is not advisable where there is a concern of an aortic dissection. After running on the treadmill for more than seven minutes, the test was terminated. Unfortunately, Mr Coxell then collapsed and died.

Coronial findings

The Coroner found that Mr Coxell died from cardiac tamponade caused by an aortic dissection due to hypertension after undertaking the exercise stress test. Importantly, the Coroner found that Mr Coxell's death was avoidable. The Coroner criticised the doctors for failing to apply clinical skills when considering other cardiac conditions that Mr Coxell might have been suffering from; placing too great a reliance on the general statistics of patients presenting to hospital with chest pain; and not obtaining advice from more senior doctors.

The Coroner made specific recommendations directed at improving the quality of the management and care of cardiac patients within the New South Wales Area Health Service. These recommendations included:

  • widening the existing guidelines to assist junior doctors with diagnosing and managing conditions
  • ensuring that senior doctors review patients when there has been a change in a patient's condition
  • developing an induction program to be presented by a senior doctor to ensure that all junior and new medical staff are familiar with the relevant protocols.

Importance of inquests

A coronial inquest into the circumstances surrounding the death of patient in a hospital is a traumatic time for friends and family of the deceased. However, it can help identify poor or risky medical practice and has the added benefit of exploring ways in which such outcomes can be prevented in the future. By participating in a coronial inquest, the family of the deceased can feel like the death of their loved one was not in vain and that changes to medical practice or behaviour may be implemented so tragedy can be avoided in the future.

Media statement