Coxell 2011 06 14 12 32 04 475

Contributing factors

• Failure to diagnose aortic dissection in Emergency Department despite clinical signs
• Over-reliance on statistical likelihood rather than clinical assessment
• Performance of exercise stress test despite recurrent chest pain
• Failure to recognize new cardiac murmur as significant finding requiring escalation
• Failure of junior doctors to escalate to on-call cardiologist
• Incomplete documentation on chest pain evaluation form
• Inadequate chest pain management protocol with insufficient guidance on alternative diagnoses
• Inadequate training and induction of junior medical staff in aortic dissection and contraindications to testing
• Poor communication and handover between junior and senior doctors

Coroner's recommendations

1. SWAHS Acute Chest Pain Protocol should be reviewed to emphasise consideration and exclusion of life-threatening conditions other than cardiac ischaemia, specifically aortic dissection, coronary artery occlusion and pulmonary embolism
2. Protocol should incorporate diagnostic guidelines for aortic dissection, coronary artery occlusion and pulmonary embolism based on current evidence-based criteria
3. Reasons for exclusion of life-threatening conditions other than cardiac ischaemia should be documented
4. All sections of the Chest Pain Evaluation ED Management Form must be completed with clear indication of the basis of any action taken, including likelihood of ischaemic heart disease, risk stratification, preliminary diagnosis and action
5. Electronic versions of the Chest Pain Evaluation ED Management Form should require completion of all sections before final action section can be filled
6. Clarify the meaning of 'recurrent pain' in Chest Pain Emergency Management Guideline to include any chest pain (typical or atypical) that has resolved and then recurred or never fully resolved
7. Replace the words 'differential diagnosis' with 'preliminary diagnosis' in guideline
8. Provide that an exercise stress test is not to be carried out in any case where the patient is experiencing any form of chest pain at the time of the proposed test
9. Clinical progress notes should make clear when patient is managed in accordance with the protocol with relevant sections easily identifiable and accessible
10. Cardiac technicians and supervising doctors should be specifically directed to ensure no test is administered if patient has any degree of chest pain at time of test or has had any chest pain between ordering and test time
11. Blacktown-Mt Druitt Hospital after-hours assessment and handover document should be amended to clarify terminology ('recurrent chest pain', 'resolve', 'instability'), incorporate early escalation to senior medical staff when clinical condition changes, and include handover by night interns
12. Following amendments, consider elevating the after-hours assessment document to status of SWAHS protocol
13. SWAHS should develop induction program presented by senior cardiologist for residents and interns caring for cardiac patients, emphasising circumstances where consultants need to be contacted and contraindications to testing procedures
14. Copy of Recommendations and Findings to be forwarded to Director, Health Services Performance Improvement Branch, NSW Department of Health for consideration in review of standardised Chest Pain Protocol