Finding into death of Salvatore Accardo

Contributing factors

• failure to obtain or integrate clinical information from ambulance, triage and nursing documentation
• reliance solely on patient history without corroboration
• atypical presentation of aortic dissection with varying symptoms over time
• absence of documented history of previously diagnosed enlarged aorta from assessment by treating physicians
• lack of integration of information systems within ED
• communication failure between paramedics and treating physician

Coroner's recommendations

1. Implementation of AAA/Aortic Dissection Guideline for Emergency Department requiring triaged Category 2 patients suspected of these conditions to be reported to ED consultant/senior registrar and vascular registrar/fellow
2. Implementation of documented responsibilities articulating that paramedics must complete electronic Patient Care Records in timely manner and place printed reports in patient record slots adjacent to cubicle
3. Ongoing review of triage processes including involvement of senior doctors at triage stage to ensure important clinical information conveyed in verbal handover is not lost
4. Improvement of information integration systems within Emergency Departments to ensure clinically relevant documented information is accessible to treating clinicians
5. Enhanced training and culture to encourage clinicians to actively incorporate information from all reasonably accessible sources, particularly in patients with known risk factors or predisposing conditions