Skip to content
recurance

Chloe Lumb

17 Feb 2022 · Coroner Karin Welsh · Teesside and Hartlepool

The coroner's concerns

  1. 1. lack of clinical guidance for suspected aortic dissection

    “There was no clinical guidance or pathway within the Emergency Department of the hospital for patients presenting with suspected aortic dissection that should have included a directive to ensure that an ECG gated CT scan is carried out to exclude the possibility of such condition”
  2. 2. no alert mechanism for genetic risk of aortic dissection

    “When the Emergency Department were contacted by Ms [name redacted] on 5th January 2021 there was no mechanism by which staff were alerted to her genetic risk of aortic dissection leading to advice merely to contact her GP”
  3. 3. absence of prior guidance for suspected aortic dissection

    “The trust identified these shortcomings prior to the Inquest and have produced a guidance or pathway document for use in the Emergency Department for suspected aortic dissection called 'Management of Adult Patients with Suspected or Proven Acute Aortic Syndromes including Aortic Dissection'”
  4. 4. lack of standard operating policy for genetic risk patients

    “Additionally they produced a Standard Operating Policy to ensure that those patients identified with genetic conditions predisposing to acute aortic syndromes have an Emergency Heath Care Plan and a CPI flag”

Responses

No published response was found on judiciary.uk.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error