Paul Sartori

Coroner's concerns

AI summary

Systemic misdiagnosis of thoracic aortic dissection is prevalent due to a lack of awareness, education among clinicians, and potentially inadequate diagnostic tools in emergency departments.

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Evidence was heard at the Inquest from an independent cardio thoracic surgeon. 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. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection.

The expert confirmed that misdiagnosis of aortic dissection is a very common problem.

During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that:

Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis:
i. Lack of awareness and education
ii. Access to CT scanning
iii. Transfers to specialist centres

The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain.

Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that 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. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to:
i. Reliably diagnose or exclude aortic dissection
ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon.

The above evidence 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.

Responses

2 respondents

Royal College of Emergency Medicine Education

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Action Taken

The Royal College of Emergency Medicine has worked to increase awareness of aortic dissection through communications, safety notices, and developing specific learning modules. It is also in the process of finalising new guidelines on the assessment of patients and identification of those requiring CT scanning. (AI summary)

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Dear Ms Persaud,

Prevention of Future Deaths Report (Mr Paul Michael Sartori)

The Royal College of Emergency Medicine is responding to the Regulation 28 Prevention of Future Deaths (PFD) Report issued on 28th April by Ms Nadia Persaud, HM Coroner East London. We wish to express our condolences to Mr Sartori’s family during this difficult time.

The Regulation 28 PFD identifies concerns regarding the management of Aortic Dissection in Emergency Department. The evidence highlighted in the Report raises concerns regarding a lack of awareness and education, access to CT scanning, and the difficulties in diagnosing aortic dissection.

Awareness and education

The Royal College of Emergency Medicine has been working on raising the awareness amongst the Emergency Department clinicians regarding aortic dissection. The Royal College of Emergency Medicine has worked to increase awareness to its members and fellows through the use of communications and safety notices as well as developing specific learning modules for members and fellows. The College is also developing guidance for the assessment of patients, and identification of those that require CT scanning (see below).

Access to CT scanning

A Healthcare Safety Investigation Branch (HSIB) investigation recently recommended that the Royal College of Emergency Medicine and the Royal College of Radiologists work together to increase the awareness of aortic dissection, the accessibility of CT scanning to diagnose aortic dissection, and to develop guidance on the identification of aortic dissection. 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. It should be remembered that CT scanning is not without its own associated harms (significant radiation exposure and kidney damage).

Difficulties in diagnosing Aortic Dissection

As was highlighted in the PFD report, the current clinical decision making tools lack sensitivity, and do not have a solid evidence base in support. There are consensus- derived tools that are based on a suite of risk factors, features in the medical history and clinical findings. These require a full assessment of the patient by a clinician. Additionally, the College is also aware that clinical findings such as blood pressure differential are not sensitive or specific enough on their own to diagnose or exclude the presence of aortic dissection. Unfortunately, there is a limited evidence-base to support a specific screening or scoring system. Patients with thoracic aortic dissection generally present with chest pain, in this group of patients a diagnosis related to coronary artery disease (eg. heart attack, angina) is approximately 100- 200 times more likely than thoracic aortic dissection, making the decision of which patients to scan particularly problematic, given this is not risk free either.

The Royal College of Emergency Medicine on several occasions has applied to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) for a national review of aortic dissection cases to help provide further evidence on this area, and is re-submitting this application this year.

Reading the details of the inquest, it is noted that this patient was seen by a General Practitioner who would not be likely to be a member of the Royal College of Emergency Medicine, and was seen in an Urgent and Emergency Care centre after ‘streaming’. These are not Emergency Departments and often are not linked to Emergency Departments. This highlights the systemic issues that exist beyond the Emergency Department and beyond the remit of the Royal College of Emergency Medicine, as identified in the PFD. This would include General Practitioners, Urgent Care Centres, and the NHS 111 system as a patient with aortic dissection may well present to all of these. It is also noted that the patient presented with chest pain and the National Guidance from the National Institute of Clinical Excellence on Chest Pain of Acute Onset (NICE CG95) does not provide clear guidance regarding screening for or consideration of aortic dissection in this group of patients. The Royal College of Emergency Medicine would therefore respectfully suggest that a number of organisations with high-level reach and importance such as NICE and NHS pathways should also be engaged with the process of raising awareness within the whole system.

Barts Health NHS Trust NHS / Health Body

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Action Taken

NELFT has completed and disseminated a dedicated learning pack on aortic dissection, while Barts Health EDs now display 'THINK AORTA' posters and incorporate the campaign into multidisciplinary teaching. The Heart Attack Centre feedback template has also been updated to prompt exclusion of aortic dissection. (AI summary)

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Dear Ms Persaud RE: Regulation 28: Report to Prevent Future Deaths write in response to the recent Regulation 28: Report to Prevent Future Deaths notice regarding the care of Paul Sartori. Please accept this as the final joint response from NELFT and Barts Health_ Paul Sartori attended Whipps Cross Hospital by ambulance on October 2019 with chest pain and was directed to the Urgent Care Centre by an Emergency Department nurse and then by a streamer_ He was assessed by a GP and discharged with a diagnosis of costochondritis_ He collapsed at home from an aortic dissection on 27ih October 2019 and could not be resuscitated The matters of concern raised in the Regulation 28 notice were: The Inquest heard evidence that the streaming guidance in place for Barts Health A & E staff and NELFT staff had not been updated to take into account the learning from the death of Mr Sartori and to take into account the guidance from the THINK AORTA Campaign (launched in
2016). 2 The nurse making the decision to re-direct Mr Sartori from A&E did not record a full set of observations, to include a pain score, prior to diverting Mr Sartori from the A & E department. The nurse did not document decision making process and rationale for redirecting Mr Sartori from A&E_ A junior sister who provided evidence at the Inquest was not aware of the THINK AORTA campaign. The Inquest heard that the senior leadership team had recently agreed to embed the THINK AORTA learning into practice at all levels within the emergency department This learning had not been embedded at the time of the Inquest hearing: Both NELFT and Barts Health are deeply sorry that the diagnosis of aortic dissection was not adequately considered when Mr Sartori sought our care_ We have approached this matter great seriousness and a mutual determination to learn and improve both our individual processes and the way we work together: Regarding the first matter_of_concern 24th her

NHS Barts Health NHS Trust NELFT and Barts Health have worked closely to review the current streaming guidance and incorporate the learning from the 'THINK AORTA' campaign. The guidance was reviewed on 18m 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 8h June 2021. Regarding the second matter of concern Whipps Cross will ensure that the pre-arrival documentation made on CRS when ambulances arrive includes documentation supporting any decision to divert the patient to the Urgent Care Centre. This will include vital signs observations and pain score and will be implemented by 15th June: A process to do this at other Barts Health Emergency Departments is already in place_ NELFT staff are aware and have been instructed that they are to document the rationale for transfer of care from the Urgent Care Centre to the Emergency Department on the patient electronic system. Urgent Care staff will also ensure that all observations are rechecked on arrival to the Urgent Care Centre and documented in the patient's record: This will be randomly manually audited_ Regarding the third matter of concern As previously described in their letter to you dated 10th May 2021, NELFT have completed and disseminated a dedicated team learning pack on aortic aneurysm dissection, and this will be reinforced at monthly clinician team meetings for NELFT urgent care practitioners. All Barts Health Emergency Departments now display "THINK AORTA" posters in prominent positions and incorporate the "THINK AORTA campaign as a recurring topic of education in departmental multidisciplinary teaching: learning piece describing the clinical characteristics of aortic dissection seen in our local population will be shared in departmental teaching during June and this will be refreshed and shared iteratively alongside scheduled "THINK AORTA" teaching: The Barts Health Heart Attack Centre feedback template has been updated to prompt exclusion of aortic dissection as a cause of non-cardiac chest pain: Thank you for communicating your concerns to uS we believe that our services are safer as a result of the action we have taken to address them_

Report sections

Investigation and inquest

On the 7th November 2019 I commenced an investigation into the death of Mr Paul Sartori 38 years old. The investigation concluded at the end of the inquest on 22nd April 2021. The conclusion of the inquest was a narrative conclusion:

Paul Sartori died from a dissecting aortic aneurysm on the 27 October 2019. He sought emergency medical assistance for central chest pain on the 24 October 2019. He was taken by ambulance to A&E, but directed away from the A&E department, to the urgent care centre by an emergency department nurse. He underwent an assessment by a general practitioner in the urgent care centre. The general practitioner formed the impression of costochondritis (musculoskeletal chest pain). Mr Sartori was advised to take analgesia and to seek medical advice if pain did not improve or if symptoms worsened. Mr Sartori suffered increasing chest pain on the 27 October 2019. An ambulance attended, but sadly, Mr Sartori did not respond to resuscitation efforts. No specific investigations were undertaken to rule out potentially lethal causes of the acute chest pain when Mr Sartori presented to A&E on the 24 October 2019. Had bilateral blood pressures and a CT scan been carried out on the 24 October 2019, it is likely that Mr Sartori’s death would have been avoided.

4. CIRCUMSTANCES OF THE DEATH

As can be seen from the narrative conclusion, Paul Sartori sought emergency medical assistance for central chest pain on the 24th October 2019. The previous day he had begun to suffer from arm pain. On the morning of the 24th October 2019 he reported to the emergency operator that he had been suffering from clamminess and sweating, followed by numbness in his hand. On attendance of the paramedics at 0630, he had a pain score of 7 out of 10 and a raised heart rate of 107 and 108. The pain score reduced at 06:50 to 4 out of 10. The paramedics determined that he should be taken to A & E to investigate the cause of the chest pain.

Mr Sartori was taken to A & E where an A & E nurse took an incomplete set of observations and redirected Mr Sartori to the urgent care centre. There is no record of the A&E nurse’s assessment.

In the urgent care centre, Mr Sartori was assessed by a GP who made a diagnosis of costochondritis.

Mr Sartori left the hospital without any further investigation or treatment. He continued to suffer from pain which became acutely worse on the morning of the 27th October 2019. At this time an ambulance was called but he was found to be unresponsive in his home address. Resuscitation efforts were provided but he was pronounced life extinct in his address on the 27th October 2019.

A post-mortem examination found that Mr Sartori had suffered a ruptured dissecting aortic aneurysm of the ascending thoracic aorta.

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who in my opinion should receive itYou may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 28th April 2021 [SIGNED BY CORONER]

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