The death of a Clutha man from an uncommon medical event will be the focus of an academic paper, to be written for the education of medical professionals.
When doctors could not establish the cause of the death of James William Dunlop (60), formerly of Clydevale, Balclutha, in Dunedin Hospital on October 28, 2009, the Otago-Southland coroner, David Crerar, investigated.
In his finding on Mr Dunlop's death, released this week, Mr Crerar found pain caused Mr Dunlop to first see a doctor in Balclutha six days before his death.
At that visit and subsequent ones, Mr Dunlop denied having had heart problems and said there was no family history of heart problems, although it later became evident there were.
He was diagnosed with a gastric or reflux-type problem by a locum doctor and again by his own GP, Keith Abbott, a few days later.
Dr Abbott sent Mr Dunlop to Dunedin Hospital two days later, after blood tests showed indications of a possibly more serious problem, although Dr Abbott thought it likely to be an infection.
Hospital investigations (including an ECG) showed signs Mr Dunlop had suffered a "heart attack" at some stage during the previous several days.
He died the next morning.
A postmortem showed Mr Dunlop had suffered several heart attacks and a ruptured left ventricle, a well-known event, but uncommon and which might mask symptoms often or usually exhibited in a heart attack, Mr Crerar found.
The median time of such a rupture before death was about five days and it was likely a patient suffering from such a rupture was irretrievable from that instant.
The effects of such a rupture were unlikely to have been immediate and were difficult to diagnose.
In his report, Mr Crerar said Mr Dunlop's children raised concerns with him that had their father been properly tested by the GP, the heart attack would have been picked up earlier, and he might have got appropriate treatment earlier.
Mr Crerar agreed Dr Abbott should have done tests to exclude a cardiac event, but other than that, faced with the patient presenting with unusual symptoms and suffering what was later found to be an uncommon event, found the doctor had examined and treated Mr Dunlop to an appropriate professional standard.
He noted other medical professionals had told him they felt it was a case of "there but for the grace of God go I" in making an incorrect diagnosis in such a case.
In retrospect, Dr Abbott had accepted he should have done more tests, Mr Crerar said.
An independent medical expert involved in the inquest, Dr G. Vause, told the inquest the case was so unusual it would be appropriate to make reference to it, in the future, for training purposes.
Mr Crerar recommended Dr Vause continue with his indication he would present an academic paper based on the circumstances of the death of Mr Dunlop, drawing his colleagues' attention to his findings.
