Joseph Cardona: ‘Systemic issues’ at play in man’s death from rare condition

A man’s family was left questioning the “adequacy” of his care after he died in an overcrowded emergency department in Melbourne’s west.

A Victorian Coroner has found “systemic issues” at Sunshine Hospital resulted in missed opportunities to diagnose and treat a man’s fatal rare heart condition.

Joseph Cardona, of Melton West, died in the emergency room at Sunshine Hospital on June 10, 2017, after being discharged the previous day despite family concerns.

The 49-year-old had been taken to the hospital on June 9 after experiencing a sudden onset of severe chest pain.

After he was reviewed by a doctor, he was sent home later that day with a discharge note indicating he should follow up on the results of a heart imaging test with his GP.

Just 12 hours later, Mr Cardona was rushed back to the hospital at 5.54am and “unexpectedly” died following a seizure while waiting to be seen.

The coroner heard there was “widespread” overcrowding and inadequate senior staffing levels at Sunshine Hospital when Joseph Cardona died. Picture: Ian Currie.

An autopsy three days later identified the cause of death to be an aortic dissection, a “very rare” condition in which a tear occurs in the main artery preventing the heart from pumping.

Mr Cardona’s family raised concern with the Coroners Court about the adequacy of the clinical management provided prior to his death.

An investigation into the death by the Coroners Prevention Unit found chronic and widespread ED overcrowding and inadequate senior staffing levels at Sunshine Hospital led to a significant delay in providing treatment to Mr Cardona.

The unit also found diagnostic tools used during his first assessment at the hospital were likely only focused on coronary artery disease, lacking an “appropriate and thorough broad diagnostic consideration”.

Coroner Paresa Antoniadis Spanos, who noted she took on the matter due to an interest in the misdiagnosis of this condition, found he was discharged on June 9 without an adequate diagnosis or explanation for his pain.

“The available evidence supports a finding that Mr Cardona’s death was preventable in the sense that his presentations to the ED on 9 June and again on 10 June, 2017, were lost opportunities for diagnosis of the aortic dissection,” she wrote.

In her finding into the death, Ms Spanos wrote it was “concerning” that missed opportunities to treat this condition were a “common theme” in Victorian hospitals.

She noted three similar cases investigated previously and reiterated calls for wider awareness of possible diagnoses for heart pain and adoption and training for a clinical risk too for aortic dissections.

She has written to Safer Care Victoria to open a dialogue on opportunities to improve the diagnosis of aortic dissections in emergency departments.