Concerns raised 4
Lack of clinical interpretation and action guidance for aortic dissection risk scores View source Confusing classification of aortic aneurysm and dissection guidance View source Failure to recognise and urgently manage suspected aortic dissection View source
Unclear interpretation of blood pressure in suspected aortic dissection View source See 1 more concern
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
JOHN SOUTHAM KEEN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Southam Keen, who had a known ascending aortic aneurysm, developed sudden chest pain radiating to his back and neck at home on 19 August 2023. Paramedics recorded the aneurysm incorrectly as abdominal and took him to a local acute hospital rather than directly to a specialist arterial centre; after a delay, he suffered cardiac arrest before surgery, sustained a fatal hypoxic brain injury and died on 24 August 2023. The report raises concerns about the paramedics’ assessment, SWAST NHS’s inadequate incident review, and confusing and unclear ambulance guidance on suspected aortic dissection.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clinical interpretation and action guidance for aortic dissection risk scores
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk . This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” Source location JOHN SOUTHAM KEEN · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Confusing classification of aortic aneurysm and dissection guidance
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm , which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning, or how the issue of a patient’s blood pressure may be relevant to overall clinical risk.
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” Source location JOHN SOUTHAM KEEN · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise and urgently manage suspected aortic dissection
Wider context from the report “1)
It is unfortunately clear, when comparing the evidence heard at the inquest with the findings of SWAST NHS’s clinical review, that there was inadequate analysis of this incident by SWAST NHS, with concerning circumstances surrounding the care provided by attending paramedics not being identified and analysed properly – therefore whether there were any appropriate recommendations to inform future care provision were not considered by SWAST NHS.
All clinical witnesses that gave evidence at the inquest (with the exception of the author of SWAST NHS’s clinical review) stated that the combination of knowing that Mr Keen had an ascending aortic aneurysm with him presenting with sudden onset chest pain radiating to his back, should have alerted attending paramedics to the real possibility of an aortic dissection . Given this and the gravity of this potential situation, it is clear that Mr Keen should have been taken directly from his home to the tertiary arterial centre by emergency ambulance transfer . If this had happened, Mr Keen would have undergone life-saving cardiothoracic surgery a number of hours earlier than he did.
SWAST NHS’s clinical review did not identify (until the error was pointed out to them during the coronial investigation) that attending paramedics incorrectly recorded that Mr Keen had an abdominal aortic aneurysm, as opposed to an ascending aortic aneurysm. Accordingly, the clinical review did not consider how this error may have occurred. The clinical review went on to conclude that Mr Keen was not demonstrating symptoms to attending paramedics which would indicate a possible aortic dissection – at the inquest, the author of SWAST NHS’s clinical review maintained that this was SWAST NHS’s view and, even when taking into consideration Mr Keen’s correct medical history (having an ascending aortic aneurysm) together with his presenting symptoms of sudden onset rad iating chest pain, SWAST NHS did not consider that an aortic dissection was a potential differential diagnosis that needed urgent investigation .
The inquest heard from an associate specialist in emergency medicine and consultant cardiologist, both of whom considered that Mr Keen’s presentation and known medical history should have resulted in there being a high degree of suspicion that he was suffering with an aortic dissection on 19 August 2023. It is also clear that the consultant in emergency medicine who assessed Mr Keen when he arrived at hospital, and who considered his known history and his presenting symptoms on that day, held such suspicion and immediately ordered imaging to confirm whether there was an aortic dissection. Therefore, a clear finding of fact was made at the inquest that SWAST NHS’s clinical review fell into error when it concluded, firstly, that it was reasonable for attending paramedics to consider it unlikely that Mr Keen was suffering an aortic dissection and, secondly, that Mr Keen was correctly taken for assessment to the local acute hospital.
If SWAST, during their internal review and investigation, do not identify an accurate factual background together with any concerns in relation to clinical care provided by their clinicians, and do not take steps to try and learn from these incidents when they occur, then there is an obvious, significant and continuing risk of future deaths occurring arising out of healthcare provision provided by SWAST NHS.
” Source location JOHN SOUTHAM KEEN · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unclear interpretation of blood pressure in suspected aortic dissection
Wider context from the report “2)
Although responsibility for the content of the Joint Royal Colleges Ambulatory Liaison Committee (JRCALC) clinical guidelines does not lie with SWAST NHS (its lies with this named committee, which is part of the AACE, and therefore they have been asked to respond to the concerns raised here about a guideline – see below) it is important that ambulance trusts consider issues relating to paramedic guidance and that their views feed in to the work of JRCALC. Therefore, the same concern that is set out below for the attention of JRCALC is raised with SWAST NHS here, for them to consider the issues raised and to formally respond with their views.
At the inquest, the content of SWAST NHS’s vascular emergencies guideline was considered. SWAST NHS confirmed that this local guideline was based on the JRCALC national vascular emergencies guideline (which had last been updated in July 2025) and that the substantive provisions in respect of clinicians considering a potential aortic dissection were set out in accordance with the national guideline.
All those involved at the inquest who both asked and answered questions about this guideline (including myself, counsel for Mr Keen’s family and the author of SWAST NHS’s clinical review) considered that it was confusing, potentially contradictory and not at all user-friendly for paramedics. In particular, concerns were raised that:
- there is a section entitled ‘aortic aneurysms’, but when the detail of this section is considered it becomes apparent that this only relates to potential rupture of an abdominal aortic aneurysm. There is then a separate section entitled ‘aortic dissection’ and it is clear that this relates primarily to ascending and descending aortic aneurysms, but also in some respects to abdominal aneurysms. The headings of these sections are confusing and it is not easily apparent which one should be considered in respect of each different type of aneurysm, which is of course particularly relevant to presenting symptoms, particularly location of pain.
- in the ‘aortic dissection detection risk score’ table of the guideline, there are a number of predisposing conditions, pain features and examination findings listed as relevant to a calculation of risk. There is then a total possible score of 0 – 3, presumably depending on whether a risk factor is present in each of the three columns – however, there is then no information about what should happen given any particular score or how the total score should affect a clinician’s impression of clinical risk. This appears to be unhelpful.
- hypotension on examination is listed as a risk factor in this risk score table, however later on in the guidance (in a section headed ‘risk factors’) it is stated that ‘hypotension is a poor prognostic sign’. Immediately above this it is stated that ‘blood pressure may be high as a consequence of the dissection’. It is therefore unclear whether, in respect of a potential aortic dissection, high or low blood pressure is concerning , or how the issue of a patient’s blood pressure may be relevant to overall clinical risk .
- overall, the impression of those discussing and analysing this guidance at the inquest was that it was confusing, lacking in detail and clarity in some respects, but unhelpfully long-winded and unclear in others. Further, it was mentioned that this guidance compares unfavourably to other documents used in similar clinical situations, including the ‘Manchester Triage System’ for suspected aortic dissection, which the inquest heard was used in some emergency departments in the UK and sets out, on one page, what the concerning symptoms are which should raise the possibility of a patient suffering an aortic dissection, and how these should then inform the urgency of the clinical response.
” Source location JOHN SOUTHAM KEEN · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the national vascular guideline with AACE against the inquest findings and engage in developing clearer guidance language.
Verbatim wording from the response “In response to the inquest, a senior member of the Trust met with the Clinical Support Managers for AACE on 17 June 2026 to review the national vascular guideline against findings.” Source location Response from South Western Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fully revise and update the aortic aneurysms section to remove confusion and improve clarity.
Verbatim wording from the response “1. Section titled ‘aortic aneurysms’” Source location Response from Association of Ambulance Chief Executives
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide improved remote clinician support through a single telephone access point to senior clinical advice.
Verbatim wording from the response “This information is not included in national JRCALC guidance, as it is region-specific. It is acknowledged that any guideline covering the recognition of aneurysms faces the inherent challenge posed by both atypical and overlapping symptoms. In such situations, ambulance clinicians rely on their professional judgement to determine the most appropriate clinical pathway. The Trust introduced improved remote clinician support for” Source location Response from South Western Ambulance Service NHS Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review aortic aneurysm and dissection guidance with paramedic input to improve usability.
Verbatim wording from the response “Your matter of concern was brought to the attention of JRCALC, and specifically to the clinical leads for the vascular emergencies guideline. These clinical leads are our expert advisors who have a background in vascular and surgical knowledge and have offered to support this work. They are currently reviewing the sections of guidance that relate to aortic aneurysms and aortic dissections. As part of this process of review, we will ensure paramedic input to the guidance is as user friendly as possible. We had an initial meeting on the 22 June 2026 to discuss your concerns which I have summarised below.” Source location Response from Association of Ambulance Chief Executives
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend hypotension wording to clarify the relevance of high and low blood pressure.
Verbatim wording from the response “3. Hypotension as a risk factor” Source location Response from Association of Ambulance Chief Executives
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The hospital-validated risk score would lead to actions unavailable in pre-hospital care, such as D-Dimer testing.
Verbatim wording from the response “The detection risk score table was included in a revision of the guideline in 2024. We aimed to assist in identifying the more subtle signs of vascular emergencies that may be missed. As this clinical risk stratification tool is not specifically designed for pre-hospital use, and only validated for hospital assessment, calculating a risk score would lead to actions that cannot be undertaken in the pre-hospital setting, for example D-Dimer testing. The tool was modified so that if any score was positive in any column, it was recommended that the patient should be conveyed to hospital. We recognise this information may be improved with updated formatting of the table.” Source location Response from Association of Ambulance Chief Executives
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation JRCALC is responsible for updating the national vascular guidance in line with the recommendations.
Verbatim wording from the response “During this discussion, AACE identified potential improvements to the language used within the clinical guidance to enhance clarity, particularly around the use of the acronym ‘AAA’. We are also aware that JRCALC are updating the Vascular guidance in line with the recommendations. The Trust is supportive of these proposed changes and will continue to engage proactively in their development.” Source location Response from South Western Ambulance Service NHS Trust
Open published response
Concerns raised 1
Insufficient practice staff awareness of dissecting aortic aneurysm View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Wayne MILNE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Wayne Milne attended hospital with chest pain on 28 February 2022 but was discharged without required chest-pain assessments and senior review. On 2 March 2022, after reporting further symptoms to his GP practice, he was advised to attend the emergency department, but the nurse did not call 999, escalate to a doctor, or check whether he had obtained urgent care; Wayne was later found deceased at home from haemopericardium due to a dissecting aortic aneurysm. The report identifies concerns about inconsistent procedures for summoning emergency assistance, escalation and follow-up, and awareness of dissecting aortic aneurysm within the practice.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient practice staff awareness of dissecting aortic aneurysm
Wider context from the report “2. The nurse at the practice told the Inquest, the procedure for practice staff calling 999 (not leaving it to the patient) in the event of a patient with chest pain and other life threatening conditions applied only to reception staff and not to nursing staff. This led to inconsistency and in this case an avoidable delay in summoning urgent medical assistance and needs reviewing/all staff working in/working on behalf of the practice need to be aware of the procedure to be followed, consideration must be given as to whether it is appropriate to have different standards for qualified nursing and administrative/non qualified nursing staff. The awareness of Dissecting Aortic Aneurysm and the rapidity at which the condition can become catastrophic/fatal also needs raising within the practice .
The nurse within the practice who spoke with Wayne on the date of his death on behalf of the practice , did not escalate to a doctor, did not call 999, she did not inform the NOK of her concerns, she did not call back to see if Wayne had called for an ambulance/attended hospital and she did not alert the hospital of her suspicions i.e. differential diagnoses including; PE, cardiac related problem or aortic aneurysm. The GP to whom this regulation 28 (Prevention of Future death) report is addressed informed the court (in a witness statement) no action had been taken within the practice since these events.
” Source location Wayne MILNE · Prevention of Future Deaths report
Open source report
17 Feb 2022 Chloe May Lumb · Prevention of Future Deaths report Teesside and Hartlepool
View report summary
Concerns raised 1
Lack of clinical guidance or pathway for suspected aortic dissection requiring ECG-gated CT scanning View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Chloe May Lumb · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Chloe May Lumb, who was known to have a genetic risk of aortic dissection, died in Redcar on 8 January 2021. She presented to hospital on 4 January with clinical symptoms and imaging findings, but the dissection was not diagnosed, and when she contacted the hospital on 5 January because of ongoing symptoms, she was advised to contact her GP rather than return to hospital. The principal concerns were the absence of an Emergency Department pathway requiring an ECG-gated CT scan for suspected aortic dissection and the lack of a mechanism alerting staff to her genetic risk.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clinical guidance or pathway for suspected aortic dissection requiring ECG-gated CT scanning
Wider context from the report “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 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
” Source location Chloe May Lumb · Prevention of Future Deaths report
Open source report
28 Apr 2021 Mr Paul Sartori · Prevention of Future Deaths report East London
View report summary
Concerns raised 4
Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection View source Insufficient access to CT scanning for suspected aortic dissection View source Failure to recognise and diagnose acute thoracic aortic dissection View source
Failures in transfer of patients with suspected aortic dissection to specialist centres View source See 1 more concern
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mr Paul Sartori · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Paul Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient sensitivity of decision-making and risk-scoring tools for aortic dissection
Wider context from the report “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.
” Source location Mr Paul Sartori · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient access to CT scanning for suspected aortic dissection
Wider context from the report “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.
” Source location Mr Paul Sartori · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise and diagnose acute thoracic aortic dissection
Wider context from the report “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 .
” Source location Mr Paul Sartori · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failures in transfer of patients with suspected aortic dissection to specialist centres
Wider context from the report “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.
” Source location Mr Paul Sartori · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise guidance for assessing patients and identifying those requiring CT scanning for suspected aortic dissection.
Verbatim wording from the response “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).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and disseminate a dedicated NELFT learning pack on aortic dissection.
Verbatim wording from the response “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.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce aortic dissection learning at monthly NELFT urgent care practitioner meetings.
Verbatim wording from the response “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.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Incorporate THINK AORTA as a recurring topic in Barts Health Emergency Department multidisciplinary teaching.
Verbatim wording from the response “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.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share and iteratively refresh a local clinical learning piece on aortic dissection alongside scheduled THINK AORTA teaching.
Verbatim wording from the response “A 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 the scheduled “THINK AORTA” teaching.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Barts Health Heart Attack Centre feedback template to prompt exclusion of aortic dissection in non-cardiac chest pain.
Verbatim wording from the response “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.” Source location 2021-0123-Response-from-Royal-London-Hospital-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise clinician awareness of aortic dissection through communications and safety notices.
Verbatim wording from the response “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).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop specific aortic dissection learning modules for members and fellows.
Verbatim wording from the response “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).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Circulate the CT-scanning guideline to members and publish it on the College website.
Verbatim wording from the response “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).” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE and NHS Pathways should help raise awareness of aortic dissection across the whole healthcare system.
Verbatim wording from the response “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.” Source location 2021-0123-Response-from-Royal-College-of-Emergency-Medicine-Redacted
Open published response
4 Sep 2020 Zoe Amanda Knight · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Overlap between aortic dissection and other cardiac-condition symptoms impeding or delaying diagnosis View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Zoe Amanda Knight · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Zoe Amanda Knight developed chest pain and other symptoms, was taken to hospital, and deteriorated after a brief seizure while being investigated for ischaemic heart disease and pulmonary embolism. A post-mortem examination concluded that she died from a dissecting aneurysm of the thoracic aorta. The report raised concerns about the overlap of symptoms with other cardiac conditions, delayed recognition of aortic dissection, and the apparent non-implementation of a recommendation to add “aortic pain” as a chest-pain triage discriminator.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Overlap between aortic dissection and other cardiac-condition symptoms impeding or delaying diagnosis
Wider context from the report “1. I heard from Dr ████████, a Consultant Cardiologist at Tameside general Hospital that aortic dissection is a well-recognised, but rare condition. It has some characteristic symptoms, but these are by no means definitively diagnostic.
2. There is an overlap of the symptoms of aortic dissection with other cardiac conditions, which can impede or delay the process of diagnosis. Rupture of the aorta following dissection as suffered by Mrs Knight is a catastrophic event.
3. Dr ████████ was aware of the recommendation made by the Healthcare Safety Investigation Branch – Delayed Recognition of Acute Aortic Dissection (Healthcare Safety Investigation I2017/002b – January 2020 Edition) which contained Safety recommendation R/2020/066:
“It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.”
4. It does not appear that this recommendation has been implemented.
5. Dr ████████’s evidence was that awareness of aortic dissection was primarily through case-based learning but acknowledged that the recommendation from thee Healthcare Safety Investigation Report above would additionally raise awareness at the triage stage.
” Source location Zoe Amanda Knight · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete surveillance review of CG95, consulting experts and deciding whether additional aortic dissection guidance was needed.
Verbatim wording from the response “Reviewing this guideline” Source location Response-from-NICE-2020-0168-Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Follow up with relevant professional organisations to improve use of NICE guidance on aortic dissection.
Verbatim wording from the response “In terms of improving awareness and learning on this topic, the responsibility for the education and training of healthcare professionals rests with the relevant professional bodies, such as the Royal Colleges, the GMC and Health Education England. We regularly engage with these organisations to improve use of our guidelines, and we will follow up in relation to this issue.” Source location Response-from-NICE-2020-0168-Redacted.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE decided not to add more detailed aortic dissection diagnosis guidance because topic experts considered this inappropriate.
Verbatim wording from the response “During this review, NICE also considered whether more detailed guidance on the diagnosis of aortic dissection (or acute aortic syndrome) should be included in the guideline.” Source location Response-from-NICE-2020-0168-Redacted.pdf
Open published response
30 Oct 2019 Philip Richard Hayes · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 1
Inconsistency in approach and answers to algorithm questions indicating risk of aortic aneurysm, rupture or dissection View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Philip Richard Hayes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Philip Richard Hayes suffered an aortic dissection on 14 April 2019 and died on 18 April 2019 after delays in ambulance response and diagnosis. The principal concerns included failure to reassess the emergency response despite five subsequent calls reporting additional symptoms and deterioration, inconsistent triage and referral for clinical input, and the appropriateness of algorithm-based triage.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistency in approach and answers to algorithm questions indicating risk of aortic aneurysm, rupture or dissection
Wider context from the report “(3) Inconsistency in approach and answers to algorithm question designed
to indicate risk of aortic aneurysm/rupture/dissection
” Source location Philip Richard Hayes · Prevention of Future Deaths report
Open source report
Concerns raised 2
Lack of clarity about protocols for transfer of patients with aortic dissection View source Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kevin John Gilbert · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin John Gilbert suffered an aortic root dissection on 29 January 2015 and died after cardiac arrest during transfer from William Harvey Hospital to St Thomas’ Hospital. The concerns included confusion about transfer protocols, delay in accepting him for transfer, and refusal to escalate the decision to a consultant; the report stated that his chances of survival would have been greater had the delay been avoided.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clarity about protocols for transfer of patients with aortic dissection
Wider context from the report “• There appeared to be confusion on the part of ████████ as to the standing protocols at St Thomas’ Hospital concerning transfer of patients with a diagnosis of aortic dissection .
” Source location Kevin John Gilbert · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery
Wider context from the report “• Given that Mr Gilbert was presenting at William Harvey Hospital as an acute emergency requiring specialist surgery at a tertiary centre and that his diagnosis of suspicion made on presenting clinical symptoms by a Consultant in Accident and Emergency medicine which was confirmed by CT scan, it was not reasonable for ████████ to rely on his understanding of the procedure of accepting such patients and wait for the CT imagery before agreeing that he could be transferred .
” Source location Kevin John Gilbert · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.
Verbatim wording from the response “In January 2015, shortly after Mr Gilbert died, the referring consultant wrote to Mr Avlonitis, consultant cardiothoracic surgeon and raised concerns about the delay in transfer. Following receipt of the letter Mr Avlonitis wrote to all registrars in the Cardiothoracic Department to clarify the department’s process for accepting dissection referrals. He confirmed that all such referrals must be discussed immediately with the duty consultant and any decision to ask to review CT imagery before transfer could only be made by a consultant. The text of the email is shown below.” Source location Kevin-GILBERT-Response
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.
Verbatim wording from the response “I would also like to make the Coroner aware of a more recent change to the management of dissection referrals at the Trust. It has always been the case that there is an ‘open door’ policy for leaking abdominal aortic aneurysms, meaning they are accepted by the vascular surgical team for immediate transfer if clinically appropriate, with a guarantee that theatre and critical care capacity will be made available. This approach has now been extended to include dissections of the ascending aorta and arch such as suffered by Mr Gilbert. Therefore, from May 2016, any such referral to this Trust will be discussed immediately with the duty consultant cardiac surgeon (as outlined above), who will then be able to authorise immediate transfer if clinically indicated, with that same guarantee that theatre and critical care capacity will be made available.” Source location Kevin-GILBERT-Response
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.
Verbatim wording from the response “The Trust is absolutely committed to learning from incidents and about how care can be improved and delivered more effectively. I am confident that following the email, and the reinforcement of the message by consultant staff, that all junior staff are completely clear that dissection referrals must be reviewed immediately by the duty consultant and they understand that the transfer decision must be made by a consultant.” Source location Kevin-GILBERT-Response
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24 Nov 2014 Lara Mamula · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 1
Failure to advise hospital assessment for suspected recurrent aortic dissection View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Lara Mamula · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lara Mamula had a history of aortic dissection and Loeys-Dietz syndrome. After developing chest pain similar to that experienced during her earlier dissection, she was assessed by ambulance staff and later attended A&E, where she was diagnosed with gastritis and discharged. Five days later, she was found deceased at home; concerns included that the ambulance service did not appreciate the seriousness of her condition or the significance of her recurrent pain, and that a CT scan was not undertaken.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to advise hospital assessment for suspected recurrent aortic dissection
Wider context from the report “1. During the course of the evidence, it became clear that the Isle of Wight Ambulance Service did not appreciate the gravity of the situation when they were called out by Mrs Mamula on 12th June 2013, inasmuch as they were not aware that Loeys-Dietz syndrome predisposes those who suffer from it to have repeated thoracic aortic aneurysms and dissections. Had they known that this condition was so grave and that Mrs Mamula was complaining of the same pain which she had suffered from 2 years previously which was clearly a very ominous symptom, they could have impressed on Mrs Mamula that she would have been much safer to have been taken to hospital at that point to be thoroughly checked out with a CT scan , which would have been the only definitive way to ascertain if she was suffering a new aortic dissection.
” Source location Lara Mamula · Prevention of Future Deaths report
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Includes failures of controls specifically dedicated to recognising and responding to suspected aortic dissection, including staff awareness and education, clinical assessment, guidance and risk tools, escalation and emergency-call procedures, urgent imaging or referral, and transfer to appropriate specialist care.
