Inadequate recognition controls for atypical aortic emergencies
First to latest report 24 Nov 2014 — 14 Oct 2025
Reports that mention this concern
6
Times this concern has been raised
9
Stated actions linked to this concern
7
What this concern includes
Includes failures of training, clinical guidance, learning dissemination or other controls specifically intended to support recognition of atypical aortic aneurysm or dissection presentations.
What is not included
Excludes failures concerning generic organisational learning or policy dissemination that are not tied to atypical aortic emergencies.
Excludes referral, treatment or pathway deficiencies unless they specifically concern recognition of an atypical aortic emergency.
Excludes unrelated clinical recognition or training deficiencies involving other hazards.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England2
Royal College of Emergency Medicine2
Association of Ambulance Chief Executives1
Barts Health NHS Trust1
Isle of Wight Ambulance Service1
Isle of Wight NHS Trust1
North East London NHS Foundation Trust1
Nottingham University Hospitals NHS Trust1
Royal College of Radiologists1
NHS trust3
Executive non-departmental public body2
Health professional body2
Health-sector membership body1
Sub-organisation1
Reports and published responses 6 reports
See individual reports that have raised this concern, and the actions taken in response
Nottinghamshire
Concerns raised3
Failure to disseminate learning about atypical aortic dissections to relevant clinicians
Failure to identify learning from atypical aortic dissection cases
Potential ineffectiveness of training on atypical aortic dissections
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Nottingham University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Nottingham University Hospitals NHS Trust
Collaborate with the East Midlands Aortic Network to incorporate regional best practice and learning into Acute Aortic Dissection diagnosis improvement.
Avon
Concerns raised2
Failure of JRCALC guidelines to provide guidance on atypical vascular emergency presentations
Lack of ambulance training and knowledge on subtle signs of vascular emergencies
Linked response
Association of Ambulance Chief Executives
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Association of Ambulance Chief Executives
Review abdominal pain and vascular emergency guidelines, considering terminology on atypical aortic presentations, the aortic dissection risk score and endoleaks after repair.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Association of Ambulance Chief Executives
Training and education of ambulance staff are outside the respondent’s responsibility.
Outside remitThe respondent said that this matter was outside its role or authority.
Cheshire
Concerns raised1
Failure of diagnostic guidance to require consideration and exclusion of abdominal aortic aneurysm when diagnosing acute pancreatitis
Linked responses
National Institute for Health and Care Excellence
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
National Institute for Health and Care Excellence
Review pancreatitis guideline section 1.2 and consider revising wording about raised lipase or amylase levels and alternative conditions.
NHS England
Review the coroner’s concerns about clinical guidance for abdominal aortic aneurysm and acute pancreatitis.
National Institute for Health and Care Excellence
Amend the pancreatitis guideline to clarify that raised lipase or amylase levels support diagnosis but may occur in other conditions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
National Institute for Health and Care Excellence
Guidelines cannot cover all differential diagnoses because each guideline has a defined scope relating to specific medical conditions.
Outside remitThe respondent said that this matter was outside its role or authority.
National Institute for Health and Care Excellence
Individual clinicians are responsible for treatment decisions, using professional experience, training and clinical judgement alongside NICE guidelines.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Responsibility for relevant clinical guidelines falls outside NHS England’s remit and authority.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Concerns about relevant clinical guidelines should be referred to the organisations responsible for producing them.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cambridgeshire and Peterborough
Concerns raised1
Lack of guidance raising the profile of acute aortic dissection when chest pain radiates to the throat, neck or jaw
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
Royal College of Emergency Medicine
Royal College of Radiologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
NHS England
Include acute aortic dissection in the GIRFT chest-pain pathway for acute settings.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Royal College of Emergency Medicine and Royal College of Radiologists
Radiating chest pain does not by itself warrant mandatory TAD investigation or CTA for all such patients because benefits do not outweigh risks.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Failure to update streaming guidance in line with relevant learning and guidance
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Barts Health NHS Trust
North East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barts Health NHS Trust and North East London NHS Foundation Trust
Review and submit joint streaming guidance incorporating THINK AORTA learning for governance approval.
Isle of Wight
Concerns raised1
Lack of awareness of the serious aortic risks associated with Loeys-Dietz syndrome
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.