Zoe Amanda Knight · Prevention of Future Deaths report

On 30th July 2019, an inquest was opened into the death of Zoe Amanda Knight, who died at Tameside General Hospital on 15th July 2019 at the age of 43 years. The investigation concluded with an inquest which I heard on 28th August 2020. The conclusion was Narrative: Died as a result of a rare, naturally occurring Aortic Dissection which ruptured before the condition could be diagnosed.

Mrs Knight woke in the early hours of the morning with chest pain. She had no medical history of any cardiac disorder. She experienced paraesthesia of her right leg and episodes of vomiting and diarrhoea.

Having been taken by ambulance to hospital, she was under investigation for ischaemic heart disease and pulmonary embolism, but suffered a brief seizure. Having been referred to the radiology department for a CT head scan and a chest X-ray, Mrs Knight’s condition quickly deteriorated and extensive efforts to resuscitate her were unsuccessful.

Whilst the doctor assessing Mrs Knight in the Emergency Department was aware of aortic dissection, his focus was on ischaemic heart disease and pulmonary embolism and the origin of the seizure.

She was in hospital for about 7 hours.

A post mortem examination concluded that Ms Chapman died as a consequence of:

1a) Dissecting aneurysm of thoracic aorta; and

2) Renal transplant (2006)

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.