Paul Sartori
29 Apr 2021 · Coroner Nadia Persaud · East London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. missed diagnosis of thoracic aortic dissection
“far too many doctors are missing the diagnosis of thoracic aortic dissection”
2. systemic misdiagnosis of acute aortic dissection
“misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths”
3. delayed or incorrect treatment of acute aortic dissection
“in half of patients presenting with acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis”
4. preventable deaths from acute type A aortic dissection
“around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis”
Linked reports
Closely relatedConfidence 0.90 · 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
“During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection.”
Responses
2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted.pdf ↗· Royal College of Emergency Medicine
Stated action
“The Royal College of Emergency Medicine is in the process of finalising a Guideline, based on the limited evidence that is available on the selection of patients for CT scanning. This will be circulated to our 10,000+ members and published on our website for public viewing. It is planned that this will be endorsed by the Royal College of Radiologists, to raise awareness amongst Radiologists.”
2021-0123-Response-from-Royal-London-Hospital-Redacted.pdf ↗· Royal College of Emergency Medicine
Stated action · 30 June 2021
“The guidance was reviewed on 18" May 2021 by Clinical and Operational leads in NELFT and Barts Health. It has now been submitted to the joint governance and operational group for consideration and sign off at the next session on gh June 2021.”
Paul-Sartori-2021-0123-Barts-Health-NHS-Trust-and-North-East-London-Foundation-Trust-Redacted.pdf ↗· Barts Health NHS Trust and North East London Foundation Trust