Chloe May Lumb · Prevention of Future Deaths report

On Fourteenth January 2021 I commenced an investigation into the death of Chloe May LUMB aged 24. The investigation concluded at the end of the inquest on 11th February 2022 and established that Mrs Lumb died at ████████ in Redcar on 8th January 2021. She was known to have a genetic risk of aortic dissection and was being monitored. She presented to James Cook University Hospital Middlesbrough (South Tees NHS Foundation Trust) on 4th January 2021 when a diagnosis of aortic dissection should have been made because of her clinical symptoms and imagining that was carried out. When she contacted the hospital on 5th January 2021 because of ongoing symptoms (having been discharged earlier that day) she should have been asked to return. A diagnosis of aortic dissection and appropriate treatment would have prevented her death.

The cause of death was

1 a Acute Hemopericardium due to

1 b Ruptured Ascending Aortic Dissection due to

1 c Cystic Medial Necrosis

My conclusion was that Mrs Lumb died as a result of an undiagnosed and therefore untreated aortic dissection

Chloe May Lumb died at ████████, Redcar on 8th January 2021. She was known to have a genetic risk of aortic dissection. She presented at hospital on 4th January 2021 when a diagnosis of aortic dissection should have been made and she should have been asked to return to the hospital on the 5th January 2021. A diagnosis of aortic dissection and appropriate surgical treatment would have prevented death.

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

The trust identified these shortcomings prior to the Inquest and have produced a guidance or pathway document for use in the Emergency Department for suspected aortic dissection called ‘Management of Adult Patients with Suspected or Proven Acute Aortic Syndromes including Aortic Dissection’. Additionally they produced a Standard Operating Policy to ensure that those patients identified with genetic conditions predisposing to acute aortic syndromes have an Emergency Heath Care Plan and a CPI flag

Copies of both documents are attached