Chantelle Reed
21 Sept 2023 · Coroner Samantha Goward · Cambridgeshire and Peterborough
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. possible acute aortic dissection missed due to atypical presentation
“the feature of central chest pain that radiates to the throat and jaw stands out as important and deserving attention in guidance to raise the profile of acute aortic dissection. Emergency physicians know that chest pain radiating to the neck and jaw may indicate acute coronary syndrome, but rarely appreciate this also raises the prospect of acute aortic pain. The latter is known amongst cardiologists and cardiac surgeons but it not widely known in acute medicine. I consider there is scope for”
Linked reports
Closely relatedConfidence 0.86 · high
Earlier report
“The chest Xray taken on the 13th January 2019 showed an image which was at least at the upper end of normal and in the context of a differential diagnosis of aortic dissection should have led to a CT Aorta being undertaken.”
This report
“the feature of central chest pain that radiates to the throat and jaw stands out as important and deserving attention in guidance to raise the profile of acute aortic dissection.”
Responses
2023-0349-Response-from-NHS-England.pdf ↗· NHS England
Stated action · January 2020
“In recent years, significant work has been undertaken to raise awareness within acute care settings of the indicators of acute aortic dissection, following recommendations made by the Healthcare Safety Investigations Branch (HSIB) in January 2020 on the culmination of an investigation into delayed recognition of acute aortic dissection and an acknowledgement that there have been challenges in frontline staff diagnosis and treatment of acute aortic dissection. This included the Manchester Triage”
2023-0349-Response-from-The-Royal-College-of-Radiologists.pdf ↗· Royal College of Radiologists