Dickinson, Rick Dudley
Deceased
Rick Dudley Dickinson
Demographics
55y, male
Date of death
2013-06-27
Finding date
2016-02-17
Cause of death
Cardiac tamponade due to ruptured aortic dissection (Type A) against a background of cystic medial degeneration
AI-generated summary
Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately assess the chest pain history, conduct appropriate cardiac examination, or order immediate imaging of the chest. Although a CT scan of the lumbar spine was performed (normal), the doctor discharged Rick after he reported pain relief, requesting only basic follow-up with his GP. Rick died at home 12 hours later from cardiac tamponade due to aortic dissection. The coroner found his death was preventable; a CT chest or aortogram that evening would likely have identified the dissection, enabling urgent surgical intervention. Critical failures included incomplete history-taking, delay in ordering cardiac investigations, failure to act on a positive D-dimer result, inadequate handover between nursing staff about the chest pain history, and insufficient baseline monitoring despite atypical presentations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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
- 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
- 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
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