Coroner's Finding: Smith, James Maurice

Contributing factors

• failure to include aortic dissection in differential diagnosis at first presentation despite clinical red flags
• failure to act upon elevated blood lactate level (5 mmol/l, double normal) as marker of possible ischaemia
• misdiagnosis as musculoskeletal back pain and viral gastroenteritis
• superficial assessment at second presentation without consideration of first presentation findings
• 8-hour delay before surgical review at second presentation
• misleading radiological description of aortic dissection as 'focal' when upper extent had not been visualised
• vascular surgeon did not receive adequate information about prior presentation or incomplete imaging of dissection extent
• failure to obtain formal CT aortogram at first presentation
• poor continuity of care between ED presentations

Coroner's recommendations

1. The Medical Journal of Australia article on collaboration between coroners and emergency physicians on aortic dissection detection and management should be widely disseminated to the medical profession, particularly those in emergency facilities
2. Implement systematic protocols for considering aortic dissection in differential diagnosis when patients present with sudden severe back or abdominal pain, particularly with elevated lactate levels
3. Establish better continuity of care procedures to ensure second presentations are assessed with full knowledge of prior ED visits
4. Implement timely surgical review processes to avoid delays in assessment of acute abdominal presentations
5. Ensure clear communication of imaging findings and their limitations between radiologists and treating clinicians