First reported 24 Nov 2014•Latest report 14 Oct 2025
Definition
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.
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.
Reports
6
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
7
Described in published responses
Reports over time
Reports 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
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Collaborate with the East Midlands Aortic Network to incorporate regional best practice and learning into Acute Aortic Dissection diagnosis improvement.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2025.
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
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review abdominal pain and vascular emergency guidelines, considering terminology on atypical aortic presentations, the aortic dissection risk score and endoleaks after repair.
Stated by Association of Ambulance Chief ExecutivesStated plannedThe respondent said that this action was planned when they made their response on 15 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Training and education of ambulance staff are outside the respondent’s responsibility.
Stated by Association of Ambulance Chief ExecutivesOutside 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
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review pancreatitis guideline section 1.2 and consider revising wording about raised lipase or amylase levels and alternative conditions.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
Action
Review the coroner’s concerns about clinical guidance for abdominal aortic aneurysm and acute pancreatitis.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Amend the pancreatitis guideline to clarify that raised lipase or amylase levels support diagnosis but may occur in other conditions.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Guidelines cannot cover all differential diagnoses because each guideline has a defined scope relating to specific medical conditions.
Stated by National Institute for Health and Care ExcellenceOutside remitThe respondent said that this matter was outside its role or authority.
Position
Individual clinicians are responsible for treatment decisions, using professional experience, training and clinical judgement alongside NICE guidelines.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for relevant clinical guidelines falls outside NHS England’s remit and authority.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Concerns about relevant clinical guidelines should be referred to the organisations responsible for producing them.
Stated by NHS EnglandRedirects 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Include acute aortic dissection in the GIRFT chest-pain pathway for acute settings.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Radiating chest pain does not by itself warrant mandatory TAD investigation or CTA for all such patients because benefits do not outweigh risks.
Stated by Royal College of Emergency Medicine and Royal College of RadiologistsDisputes 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review and submit joint streaming guidance incorporating THINK AORTA learning for governance approval.
Stated by Barts Health NHS Trust and North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2021.
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.
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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Includes failures of training, clinical guidance, learning dissemination or other controls specifically intended to support recognition of atypical aortic aneurysm or dissection presentations.
