Coronial
ACThospital

Inquest Into The Death Of Peter Hanisch

Deceased

Peter Hanisch

Demographics

69y, male

Coroner

Coroner Archer

Date of death

2021-08-22

Finding date

2025-04-09

Cause of death

thoracic aortic aneurysm with dissection

AI-generated summary

Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angiogram was performed but the radiologist, Dr CD, failed to identify the aortic dissection, instead reporting only an aneurysm and dilated aortic root. The dissection was clearly observable on the CT images but was misread. Over the subsequent three days, clinicians pursued alternative diagnoses (stroke, sepsis, pulmonary embolism) based on the incorrect CT report. The coroner found that had the dissection been promptly diagnosed and treated surgically on admission, there were very reasonable prospects of saving Peter's life. The key clinical lesson is the critical importance of radiological peer review processes and the need for clinicians to maintain high clinical suspicion for aortic dissection when symptoms are consistent, even when imaging reports appear to exclude it. The case highlights gaps in quality assurance systems for imaging services.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

radiologyemergency medicineneurologycardiologyintensive care

Error types

diagnosticsystem

Clinical conditions

thoracic aortic aneurysmaortic dissectionStanford type A dissectionhypertensionhyperlipidaemiaatrial fibrillationcardiac tamponadeintramural haematoma

Procedures

CT angiographychest X-rayelectrocardiographyresuscitation

Contributing factors

  • misreading of CT angiogram by radiologist
  • failure to identify aortic dissection on imaging
  • lack of peer review of radiological report
  • pursuit of alternative diagnoses based on incorrect imaging report
  • failure to include troponin in pathology request on 22 August 2021
  • absence of formal peer review policy and procedures within health service
  • single radiologist on-site without backup review mechanisms
  • non-cardiac gating on CT scanner contributed to image quality but not causative

Coroner's recommendations

  1. CHS should develop and publish guidance as to peer review systems and procedures for imaging services provided within CHS and by private providers providing such services on behalf of CHS
  2. Guidance should apply to all imaging produced within CHS including out of hours imaging and imaging undertaken by private providers at TCH and NCH
  3. Peer review procedures should be designed to generate statistically valid profile of accuracy of image reporting
  4. Formal policies should be established governing when peer review of radiology reports should be undertaken
  5. Consideration should be given to staffing arrangements to avoid single radiologist working independently without peer review backup
  6. Systems should be implemented to enable second review of images by off-site radiologists and enhance peer review capabilities
Full text
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