Dickinson, Rick Dudley

Contributing factors

• Failure to obtain detailed history of chest pain characteristics
• Failure to perform adequate cardiovascular examination
• Inadequate triage assessment and bay allocation despite chest pain history
• Incomplete nursing handover – history of chest pain not communicated to nurses providing primary care
• Delayed ordering of cardiac investigations (ECG and blood tests ordered 2 hours after initial assessment)
• Discharge before critical test results returned, specifically D-dimer which was positive
• Failure to act on positive D-dimer result
• Failure to recall or review QAS eARF (electronic ambulance report form) which documented severity of chest pain (8/10)
• Failure to review available triage notes in electronic medical record
• Inadequate baseline monitoring – only one set of observations recorded over 2+ hours
• Discharge bay without monitoring equipment despite potential for serious pathology
• Clinical decision-making influenced by patient's expressed desire for discharge rather than clinical need
• Assumption that spontaneously resolving pain indicates benign condition

Coroner's recommendations

1. Queensland Emergency Department Strategic Advisory Panel, Australasian College of Emergency Medicine and Queensland Ambulance Service should review continuing medical education programs to ensure aortic dissection is highlighted in differential diagnosis training for patients presenting with chest and back pain
2. Queensland Health should implement procedures to ensure information in ambulance eARF is readily available to treating clinicians through integration with electronic medical records or requiring staff to document review of eARF contents