Coroner Simon Cooper has emphasised the need for staff at the Mersey Community Hospital to get properly trained in reading ECGs.
In his inquest into the 2019 death of 83-year-old Devonport woman Beryl Jean Ridgeon, Mr Cooper said if the ECG had been properly interpreted, Mrs Ridgeon may not have died.
He said it was "imperative" that staff received appropriate training in how to interpret the results of ECGs.
An ECG is a medical test that detects heart abnormalities.
Mr Cooper found that Mrs Ridgeon died of haemopericardium (a heart attack) on December 17, 2019 in Devonport.
Mrs Ridgeon was born in England in 1936, where she trained as nurse.
In 1965 she and her husband and three children migrated to Burnie, where she worked at the Burnie Hospital intensive care unit.
The family later moved to Devonport, where Mrs Ridgeon worked at the Mersey General Hospital until she retired.
The report said that on December 15, 2019, she felt unwell and couldn't keep food down.
The next day she was taken to the Mersey Community Hospital where she was diagnosed with gastroenteritis.
"Crucially, whilst at the Mersey Community Hospital, an ECG was performed.
"That ECG showed clearly that Mrs Ridgeon had suffered a myocardial infarction.
"The fact that she had suffered a myocardial infarction appears to have been completely missed by medical staff at the Mersey Community Hospital," the coroner said.
She was given nausea medication and discharged. A daughter stayed with her overnight, and on the morning of December 17 found her dead in bed.
Forensic pathologist Dr Jane Vuletic performed an autopsy at the Royal Hobart Hospital.
She found the direct cause of Mrs Ridgeon's death was a haemopericardium, underlying conditions being a ruptured acute myocardial infarction and coronary atherosclerosis.
"I accept her opinion as to Mrs Ridgeon's cause of death," Mr Cooper said.
Primary Industries and Water Minister Guy Barnett said the government would consider the findings very carefully. "I have no doubt the Attorney-General and the government will respond as appropriate, as soon as appropriate."
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