title: How on earth did this happen?
authors.affiliation: State Volunteer Mutual Insurance Company, Brentwood, USA.
authors.forename: J Kelley
authors.initials: JK
authors.lastname: Avery
mesh_terms: D002637:Chest Pain; D003324:Coronary Artery Disease / Q000175:diagnosis*; D003951:Diagnostic Errors / Q000331:legislation & jurisprudence*; D004282:Documentation; D004636:Emergency Service, Hospital; D017809:Fatal Outcome; D006801:Humans; D006973:Hypertension / Q000175:diagnosis; D017379:Hypertrophy, Left Ventricular / Q000175:diagnosis; D033183:Interdisciplinary Communication; D016365:Liability, Legal; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge