Finding into death of Constandia Petzierides

Contributing factors

• failure to diagnose acute aortic dissection in emergency department
• incomplete history taking regarding pain characteristics
• incomplete physical examination (no blood pressure differential assessment, no assessment for pulse deficits)
• misinterpretation of investigation findings (normal chest x-ray used to rule out dissection)
• misuse of normal blood pressure to exclude aortic dissection
• reliance on cardiac chest pain pathway without re-evaluation at pathway end
• failure to consider aortic dissection despite high-risk presentation features
• lack of communication of paramedic suspicions of aortic dissection to hospital staff
• discharge diagnosis of musculoskeletal pain for sudden-onset 10/10 pain
• inadequate handover of information between ambulance crews

Coroner's recommendations

1. Australasian College for Emergency Medicine should highlight in training curricula the importance of considering aortic dissection diagnosis for patients presenting with chest pain, particularly nuanced presentations. Practice of re-visiting diagnosis at end of chest pain pathway and/or review by senior clinician before discharge should be implemented.
2. Minister for Health and Department of Health should consider funding research aimed at developing and evaluating a structured clinical tool for risk stratification of patients presenting with chest pain and suspected aortic dissection.
3. Ambulance Victoria should investigate feasibility of providing receiving hospitals with all VACIS Patient Care Reports from all crews involved in patient episode of care, so that first responders' clinical impressions are available to inform hospital clinical management.