VIChospital

Finding into death of Zoran Georgievski

Deceased

Zoran Georgievski

Demographics

40y, male

Coroner

Coroner John Olle

Date of death

2011-04-07

Finding date

2015-04-10

Cause of death

haemopericardium complicating ascending thoracic aortic dissection

AI-generated summary

A 40-year-old man presented to the Northern Hospital ED with acute chest pain radiating to his throat, diaphoresis, and left hand tingling. Initial assessment by a junior doctor appropriately excluded cardiac ischaemia and he was discharged on day 2 with a diagnosis of reflux. He died two days later from rupture of an ascending thoracic aortic dissection with haemopericardium. Post-mortem imaging revealed widened mediastinum on the initial chest x-ray. The coroner found preventable failures: the x-ray was likely never properly reviewed by ED clinicians before discharge; the consultant radiologist (Dr T.) failed to identify the marked mediastinal widening and did not alert the ED; and escalation to senior imaging review on a full-resolution screen did not occur. However, the presentation was atypical for dissection, clinical suspicion was justifiably low, and junior doctors could not be expected to diagnose this subtle radiological finding. The primary failure was the radiologist's perceptual error and lack of communication.

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Specialties

emergency medicineradiologycardiothoracic surgery

Error types

diagnosticcommunicationsystem

Drugs involved

morphineaspirinpantoprazole

Clinical conditions

ascending thoracic aortic dissectionhaemopericardiumcardiac tamponade

Procedures

chest X-raycardiac enzyme testing

Contributing factors

failure of radiologist to identify widened mediastinum on chest x-ray
failure of radiologist to communicate abnormality to ED clinicians
failure of ED clinicians to view chest x-ray before discharge
failure to escalate x-ray review to full-resolution screen and senior clinician
atypical clinical presentation of aortic dissection
lack of formal handover of x-ray results between clinicians
no notification system for radiology results in place at the time
clinical suspicion for aortic dissection was appropriately low given presentation

Coroner's recommendations

The Department of Health disseminate to all Victorian Health Services a letter from Northern Health dated November 18, 2014 detailing the initiatives and improvements implemented in the Emergency Department since Zoran's death, including: formalised bedside handovers led by consultants at 0800, 1600 and 2230 hours; implementation of dedicated SSU residents with formalised handovers at 10:30 pm and 7:30 am; SSU resident paged by nursing staff when concerns arise with 15-minute assessment response time for clinically unstable patients; dedicated emergency physician independent assessment of patients; mandatory x-ray review by senior doctor before SSU admission; clinical instability criteria implementation; Patient First Application pilot with task tracking and automated alerts for outstanding radiology results; improved radiology request forms including clinical questions (such as 'Exclude Aortic Dissection?') with traffic-light approval system for senior clinician input; electronic ordering of pathology and radiology to eliminate legibility issues; clinician access to verbal radiology reports before typed reports; education of junior doctors on aortic dissection red flags and differential diagnosis; daily x-ray image review at 13:00 hours with clinical notes to identify missed abnormalities and recall of discharged patients if needed; education emphasising aortic dissection cannot be excluded by classical presentation alone and should be treated as 'subarachnoid haemorrhage of the heart'; increased awareness among clinicians of the high 30-40% error rate in radiology of abnormal images

Full text

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Source and disclaimer

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