Prevention of future deaths report – Paul Sartori

Summary

Paul Satori died as a result of a dissecting aortic aneurysm following a misdiagnosis, and being discharged from hospital.

Content

Evidence for this coroner's report raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection.

In 2020, The Healthcare Safety Investigation Branch published an investigation into delayed recognition of acute aortic dissection, which also made safety recommendations.

Follow the link below to read the coroner's report regarding Paul's death in full.