Finding into death of Sally Elizabeth Hopwood

Contributing factors

• Failure to diagnose aortic dissection in high-risk patient with Turner syndrome, coarctation of aorta, and bicuspid aortic valve
• Inadequate review of chest X-ray findings showing widened mediastinum and dilated upper aorta
• Failure to order CT chest imaging when indicated by X-ray report and clinical presentation
• Misattribution of symptoms and imaging findings to abdominal pathology rather than aortic pathology
• Inadequate handover communication between ED physician and receiving cardiologist regarding X-ray significance
• Reliance on prior normal echocardiogram while ignoring that echocardiography does not visualize descending aorta
• Failure to reconsider diagnosis when CT cholangiogram revealed bilateral effusions and lung consolidation
• Anchoring bias on abdominal diagnosis despite atypical presentation for abdominal disease

Coroner's recommendations

1. ED consultants at handover should provide full report to receiving physician with opportunity to discuss clinical significance of findings and patient history
2. Receiving physicians should participate actively in handover to ensure full understanding of investigations and their interpretation
3. In cases with fluctuating or unclear presentations, consultant specialists should conference with peers to reconsider diagnostic pathways
4. When investigation results suggest unexpected findings (e.g., lung effusions), clinicians should reconsider original diagnostic hypothesis rather than explain away findings
5. For high-risk cardiac patients, chest imaging should not rely solely on echocardiography, which does not visualize descending aorta
6. When doubt persists about diagnosis despite investigation, escalation and discussion between specialists should occur before accepting benign explanations