Summary
Chloe Lumb was known to have a genetic risk of aortic dissection that was being monitored. When she presented to James Cook University Hospital in Middlesbrough on 4 January 2021 a diagnosis of aortic dissection was not made, despite the prior knowledge about her risk and her clinical symptoms. The next day she contacted the hospital following discharge because of ongoing symptoms but was not asked to return to hospital. In her report, the Coroner states that a diagnosis of aortic dissection and appropriate surgical treatment would have prevented Ms Lumb’s death.
Content
In her report, the Coroner states the following concerns:
- 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.
- When the Emergency Department were contacted by Ms Lumb on 5 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.
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'. 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.
The Coroner states that to prevent future deaths:
- all Trusts within England should be made aware of the circumstances of this case, and particularly the necessity to have in place a similar guidance or pathway document and standard operating policy. This is to be achieved via the NHS patient safety framework.
This report was sent to the South Tees NHS Foundation Trust and the Department of Health and Social Care.
Delays in recognition of acute aortic dissection
Missed diagnosis of aortic dissection is a known patient safety issue. Concerns about this were also raised in a Coroner’s report issued in 2021 following the death of Paul Satori, who died as a result of a dissecting aortic aneurysm following a misdiagnosis, having been discharged from hospital. The report into Mr Satori’s death also raised concerns about the guidance and awareness of aortic dissection at emergency departments. The Healthcare Safety Investigation Branch also published a report into this patient safety issue in January 2020.
Related reading
- The Aortic Dissection Charitable Trust – they aim to improve the diagnosis of aortic dissection and bring consistency of treatment across the whole patient pathway.
- Healthcare Safety Investigation Branch, Investigation into delayed recognition of acute aortic dissection, 23 January 2020.
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