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A Waltham Forest man was found dead in his home just three days after being discharged from Whipps Cross A&E with a prescription for painkillers and an anti-ulcer medication.
East London coroner Nadia Persaud concluded Gavin Shwe, 39, died of “natural causes”. He was found on September 5 last year but may have died as early as September 2.
At the inquest on November 6, pathologist Dr Rowena Smith explained he suffered an “aortic dissection”, meaning his aorta tore and blood pooled around his heart and stopped it beating.
Dr Smith speculated this tearing may have already begun when Gavin attended Whipps Cross A&E on September 2, having complained of severe pain in his chest, stomach and neck.
Gavin’s mother Denise told Walthamstow Coroner’s Court she felt more should have been done to investigate his condition before he was discharged, still in pain, according to his friend.
She told the court: “He was in excruciating pain on arrival and he was discharged in the same pain. His condition was overlooked due to his age.
“I’m not saying they could have saved him but maybe he would not have gone home to die and been left there for three days, maybe he would have died with a bit of dignity.
“He may only have been home an hour when this happened, I wish it would have happened in the hospital. He would have died in their care and not the horrible way that he did.”
Gavin was taken to Whipps Cross Hospital in Leytonstone on September 2 by his friend Jason Walker after complaining of severe pain that continued for more than an hour.
Jason told the court Gavin said his stomach hurt like “someone had kicked him very hard”, that his chest felt like “there was a belt around it” and that “his heart was in his throat”.
He estimated they were in hospital for “a good three or four hours”, during which time Gavin “had to go lay down once or twice”, before he was prescribed ulcer medication and discharged.
Jason said: “He was just given some tablets and sent home, still in pain. You could see he was in severe discomfort and it had not got any better.
“He was still in a lot of pain going back to his house, even going over speed bumps was a little uncomfortable for him.”
Evidence read out from Gavin’s GP showed no record of serious physical health problems or high blood pressure, the most common cause of an aortic dissection.
Dr Smith said it is possible he had an undiagnosed connective tissue disorder, such as Marfan or Ehlers-Danlos syndrome, which may have weakened the artery.
Asked if the dissection could have been spotted at A&E, she said “a scan might have detected a dissection” but suggested his death may not have been preventable.
The court heard from Whipps Cross consultant Dr Zia, who explained Gavin’s symptoms were not the typical signs of aortic dissection but that it is a condition that can “present atypically”.
Patients normally describe pain in the centre of the chest that radiates between the shoulder blades, whereas Gavin’s pain was most severe in his stomach.
Dr Zia said that he asked a number of colleagues how they would have reacted to his symptoms, without explaining the outcome, and “every one of them said they would have discharged him”.
He added: “It’s very difficult in this case to say we should have done something different.
“I think the learning in this case is to reinforce the importance that aortic dissection can present in an atypical fashion.”
Coroner Ms Persaud concluded that, even if she did find Gavin should have been kept in hospital for observations, she could not find “on the balance of probabilities” that his death was avoidable.
She said: “We have heard that death can be very sudden. Even if he had been admitted, they might not immediately have been thinking of a cardiac case.
“It may have taken some time to get that diagnosis and to get him to St Bartholomew’s for the surgery he would have needed. The only conclusion open to me is natural causes.”